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Chen C, Hennessy S, Brensinger CM, Miano TA, Bilker WB, Dublin S, Chung SP, Horn JR, Tiwari A, Leonard CE. Comparative Risk of Injury with Concurrent Use of Opioids and Skeletal Muscle Relaxants. Clin Pharmacol Ther 2024; 116:117-127. [PMID: 38482733 PMCID: PMC11180590 DOI: 10.1002/cpt.3248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 03/02/2024] [Indexed: 05/04/2024]
Abstract
Concurrent use of skeletal muscle relaxants (SMRs) and opioids has been linked to an increased risk of injury. However, it remains unclear whether the injury risks differ by specific SMR when combined with opioids. We conducted nine retrospective cohort studies within a US Medicaid population. Each cohort consisted exclusively of person-time exposed to both an SMR and one of the three most dispensed opioids-hydrocodone, oxycodone, and tramadol. Opioid users were further divided into three cohorts based on the initiation order of SMRs and opioids-synchronically triggered, opioid-triggered, and SMR-triggered. Within each cohort, we used Cox proportional hazard models to compare the injury rates for different SMRs compared to methocarbamol, adjusting for covariates. We identified 349,543, 139,458, and 218,967 concurrent users of SMRs with hydrocodone, oxycodone, and tramadol, respectively. In the oxycodone-SMR-triggered cohort, the adjusted hazard ratios (HRs) were 1.86 (95% CI, 1.23-2.82) for carisoprodol and 1.73 (1.09-2.73) for tizanidine. In the tramadol-synchronically triggered cohort, the adjusted HRs were 0.69 (0.49-0.97) for metaxalone and 0.62 (0.42-0.90) for tizanidine. In the tramadol-SMR-triggered cohort, the adjusted HRs were 1.51 (1.01-2.26) for baclofen and 1.48 (1.03-2.11) for cyclobenzaprine. All other HRs were statistically nonsignificant. In conclusion, the relative injury rate associated with different SMRs used concurrently with the three most dispensed opioids appears to vary depending on the specific opioid and the order of combination initiation. If confirmed by future studies, clinicians should consider the varying injury rates when prescribing SMRs to individuals using hydrocodone, oxycodone, and tramadol.
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Affiliation(s)
- Cheng Chen
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Colleen M. Brensinger
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Todd A. Miano
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Warren B. Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
| | - Sascha Dublin
- Kaiser Permanente Washington Health Research Institute (Seattle, WA, US)
- Department of Epidemiology, School of Public Health, University of Washington (Seattle, WA, US)
| | | | - John R. Horn
- Department of Pharmacy, School of Pharmacy, University of Washington (Seattle, WA, US)
| | - Anika Tiwari
- College of Arts and Sciences, University of Pennsylvania (Philadelphia, PA, US)
| | - Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, PA, US)
- Leonard Davis Institute of Health Economics, University of Pennsylvania (Philadelphia, PA, US)
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Mahmoudian A, Lohmander LS, Dahlberg LE, Kiadaliri A. Digital Self-Management, Analgesic Use, and Patient-Reported Outcomes in Knee or Hip Osteoarthritis. Arch Phys Med Rehabil 2024:S0003-9993(24)01053-0. [PMID: 38866226 DOI: 10.1016/j.apmr.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/30/2024] [Accepted: 05/31/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To investigate changes in analgesic use before and after participation in a digital first-line treatment program (exercise, patient education) in persons with knee or hip osteoarthritis (OA) and to explore associations between these changes in medication use and participant-reported pain and function. DESIGN Retrospective cohort study with pre-post measures. SETTING Community setting. PARTICIPANTS Individuals (N=4100; mean age ± SD, 64.5±9.3y; 73.3% women) participating in the digital program. INTERVENTIONS A digital supervised education and exercise therapy. MAIN OUTCOME MEASURES Self-reported analgesic use for knee/hip pain during the past month at baseline and 12-week follow-up, knee/hip numeric rating scale pain (0-10, a higher value indicating more pain), and Knee Injury and Osteoarthritis Outcome Score 12 or Hip Disability and Osteoarthritis Outcome Score 12 function subscale (0-100, higher values indicating better function). McNemar test, multivariable logistic regression, and linear random intercept model were used for statistical analyses. RESULTS Among participants, 61.4% and 49.4% were analgesic users at baseline and 12-week follow-up, respectively, (absolute reduction 12.0%; 95% confidence interval, 10.5-13.5). Being female, having hip OA, lower education, higher body mass index, living outside large metropolitan cities, coexisting rheumatoid arthritis, and walking difficulties were associated with higher odds of analgesic use at baseline. At both time points, persons not using analgesics at the time reported better outcomes. All groups but "new users" experienced improvements in their pain and function following participation in digital program with the greatest improvements observed among "quitters." CONCLUSIONS Engaging in a digital exercise and patient education program as a primary treatment for knee or hip OA was associated with a reduction in the use of analgesics. The greatest improvements were seen for those who stopped analgesic use. These results highlight the importance of providing effective first-line treatment to people with knee or hip OA.
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Affiliation(s)
- Armaghan Mahmoudian
- Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden; Department of Movement Sciences and Health, University of West Florida, Pensacola, FL
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Leif E Dahlberg
- Department of Clinical Sciences Lund, Orthopaedics, Lund University, Lund, Sweden
| | - Ali Kiadaliri
- Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden.
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Thornton JD, Varisco T, Patel H, Shrestha M, Wanat M, Schaefer E, Leslie D, Zhao H, Saadi RA, Shen C. Characterising incident opioid use among incident users of prescription sedative hypnotics: A national cohort study. BMJ Open 2024; 14:e082339. [PMID: 38816043 PMCID: PMC11138274 DOI: 10.1136/bmjopen-2023-082339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/15/2024] [Indexed: 06/01/2024] Open
Abstract
OBJECTIVE To evaluate co-prescribing of sedatives hypnotics and opioids. DESIGN Retrospective study evaluating the association of patient characteristics and comorbidities with coprescribing. SETTING AND PARTICIPANTS Using the national Merative MarketScan Database between 2005 and 2018, we identified patients who received an incident sedative prescription with or without subsequent, incident opioid prescriptions within a year of the sedative prescription in the USA. OUTCOME MEASURES Coprescription of sedative-hypnotics and opioids. RESULTS A total of 2 632 622 patients (mean (SD) age, 43.2 (12.34) years; 1 297 356 (62.5%) female) received incident prescriptions for sedatives over the course of the study period. The largest proportion of sedative prescribing included benzodiazepines (71.1%); however, z-drugs (19.9%) and barbiturates (9%) were also common. About 557 845 (21.2%) patients with incident sedatives also received incident opioid prescriptions. About 59.2% of these coprescribed patients received opioids coprescription on the same day. Multivariate logistic regression findings showed that individuals with a comorbidity index score of 1, 2 or ≥3 (aOR 1.19 (95% CI 1.17 to 1.21), 1.17 (95% C 1.14 to 1.19) and 1.25 (95% C 1.2 to 1.31)) and substance use disorder (1.21 (95% C 1.19 to 1.23)) were more likely to be coprescribed opioids and sedatives. The likelihood of receiving both opioid and sedative prescriptions was lower for female patients (aOR 0.93; 95% CI 0.92 to 0.94), and those receiving a barbiturate (aOR 0.3; 95% CI 0.29 to 0.31) or z-drugs (aOR 0.67; 95% CI 0.66 to 0.68) prescriptions at the index date. CONCLUSIONS Coprescription of sedatives with opioids was associated with the presence of comorbidities and substance use disorder, gender and types of sedatives prescribed at the index date. Additionally, more than half of the coprescribing occurred on the same day which warrants further evaluation of current prescribing and dispensing best practice guidelines.
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Affiliation(s)
- James Douglas Thornton
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Tyler Varisco
- Department of Pharmaceutical Health Outcomes and Policy, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Harshil Patel
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Mina Shrestha
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Matthew Wanat
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Eric Schaefer
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Douglas Leslie
- Center for Applied Studies in Health Economics, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Randa Al Saadi
- Prescription Drug Misuse Education and Research (PREMIER) Center, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Chan Shen
- Division of Outcomes Research and Quality, The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
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Calabrese MJ, Shaya FT, Palumbo F, McPherson ML, Villalonga-Olives E, Zafari Z, Mutter R. State-level policies and receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users. J Opioid Manag 2024; 20:149-168. [PMID: 38700395 DOI: 10.5055/jom.0824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
OBJECTIVES To evaluate the association of state-level policies on receipt of opioid regimens informed by Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day recommendations. DESIGN A retrospective cohort study of new chronic opioid users (NCOUs). SETTING Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new chronic use between January 2014 and March 2015. PARTICIPANTS NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid prescription. INTERVENTIONS State-level policies including Prescription Drug Monitoring Program (PDMP) robustness and cannabis policies involving the presence of medical dispensaries and state-wide decriminalization. MAIN OUTCOME MEASURES NCOUs were placed in three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). Multinomial logistic regression was used to estimate the association of state-level policies with the thresholds while adjusting for relevant patient-specific factors. RESULTS NCOUs in states with medium or high PDMP robustness had lower odds of receiving medium (adjusted odds ratio [AOR] 0.74; 95 percent confidence interval [CI]: 0.62-0.69) and high (AOR 0.74; 95 percent CI: 0.59-0.92) thresholds. With respect to cannabis policies, NCOUs in states with medical cannabis dispensaries had lower odds of receiving high (AOR 0.75; 95 percent CI: 0.60-0.93) thresholds, while cannabis decriminalization had higher odds of receiving high (AOR 1.24; 95 percent CI: 1.04-1.49) thresholds. CONCLUSION States with highly robust PDMPs and medical cannabis dispensaries had lower odds of receiving higher opioid thresholds, while cannabis decriminalization correlated with higher odds of receiving high opioid thresholds.
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Affiliation(s)
- Martin J Calabrese
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy; Center for Medicare, Centers for Medicare & Medicaid Services, Baltimore, Maryland. ORCID: https://orcid.org/0000-0003-4304-396X
| | - Fadia T Shaya
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Francis Palumbo
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Mary Lynn McPherson
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Ester Villalonga-Olives
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Zafar Zafari
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Ryan Mutter
- Congressional Budget Office, Health Analysis Division, Washington, DC
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Calabrese MJ, Shaya FT, Palumbo F, McPherson ML, Villalonga-Olives E, Zafari Z, Mutter R. Short-term healthcare resource utilization associated with receipt of CDC-informed opioid thresholds among commercially insured new chronic opioid users. J Opioid Manag 2024; 20:31-50. [PMID: 38533714 DOI: 10.5055/jom.0848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVE To evaluate the impact of recent changes to the Centers for Disease Control and Prevention (CDC) morphine milligram equivalent (MME)/day threshold recommendations on healthcare utilization. DESIGN A retrospective cohort study of new chronic opioid users (NCOUs). SETTING Commercially insured plans across the United States using IQVIA PharMetrics® Plus for Academics database with new use between January 2014 and March 2015. PATIENTS NCOUs with ≥60-day coverage of opioids within a 90-day period with ≥30-day opioid-free period prior to the date of the first qualifying opioid -prescription. INTERVENTIONS NCOU categorized by the CDC three-tiered risk-based average MME/day thresholds: low (>0 to <50), medium (≥50 to <90), and high (≥90). MAIN OUTCOME MEASURES Multivariable logistic regression was used to calculate adjusted odds of incurring an acute care encounter (ACE) (all-cause and opioid-related) between the thresholds (adjusted odds, 95 percent confidence interval). RESULTS In adjusted analyses, when compared to low threshold, there was no difference in the odds of all-cause ACE across the medium (1.01, 0.94-1.28) and high (1.01, 0.84-1.22) thresholds. When compared to low threshold, a statistically insignificant increase was observed when evaluating opioid-related ACE among medium (1.86, 0.86-4.02) and high (1.51, 0.65-3.52) thresholds. CONCLUSIONS There was no difference in odds of an all-cause or opioid-related ACE associated with the thresholds. Early-intervention programs and policies exploring reduction of MME/day among NCOUs may not result in short-term reduction in all-cause or opioid-related ACEs. Further assessment of potential long-term reduction in ACEs among this cohort may be insightful.
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Affiliation(s)
- Martin J Calabrese
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy; Center for Medicare, Centers for Medicare & Medicaid Services, Baltimore, Maryland. ORCID: https://orcid.org/0000-0003-4304-396X
| | - Fadia T Shaya
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Francis Palumbo
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Mary Lynn McPherson
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Ester Villalonga-Olives
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Zafar Zafari
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland Baltimore School of Pharmacy, Baltimore, Maryland
| | - Ryan Mutter
- Congressional Budget Office, Health Analysis Division, Washington, DC
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Canizares M, Power JD, Perruccio AV, Veillette C, Mahomed N, Rampersaud YR. Time trends and patterns in opioid prescription use following orthopaedic surgery in Ontario, Canada, from 2004/2005 to 2017/2018: a population-based study. BMJ Open 2023; 13:e074423. [PMID: 37963700 PMCID: PMC10649703 DOI: 10.1136/bmjopen-2023-074423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 10/26/2023] [Indexed: 11/16/2023] Open
Abstract
OBJECTIVES Increased use of opioids and their associated harms have raised concerns around prescription opioid use for pain management following surgery. We examined trends and patterns of opioid prescribing following elective orthopaedic surgery. DESIGN Population-based study. SETTING Ontario, Canada. PARTICIPANTS Ontario residents aged 66+ years who had elective orthopaedic surgery from April 2004 to March 2018. PRIMARY AND SECONDARY OUTCOME MEASURES Postoperative opioid use (short term: within 90 days of surgery, prolonged: within 180 days and chronic: within 1 year), specific opioids prescribed, average duration (days) and amount (morphine milligram equivalents) of the initial prescription by year of surgery. RESULTS We included 464 460 elective orthopaedic surgeries in 2004/2005-2017/2018: 80% of patients used opioids within 1 year of surgery-25.1% were chronic users. There was an 8% increase in opioid use within 1 year of surgery, from 75.1% in 2004/2005 to 80.9% in 2017/2018: a 29% increase in short-term use and a decline in prolonged (9%) and chronic (22%) use. After 2014/2015, prescribed opioid amounts initially declined sharply, while the duration of the initial prescription increased substantially. Across categories of use, there was a steady decline in coprescription of benzodiazepines and opioids. CONCLUSIONS Most patients filled opioid prescriptions after surgery, and many continued filling prescriptions after 3 months. During a period of general increase in awareness of opioid harms and dissemination of guidelines/policies aimed at opioid prescribing for chronic pain, we found changes in prescribing practices following elective orthopaedic surgery. Findings illustrate the potential impact of guidelines/policies on shaping prescription patterns in the surgical population, even in the absence of specific guidelines for surgical prescribing.
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Affiliation(s)
- Mayilee Canizares
- Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - J Denise Power
- Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Anthony V Perruccio
- Schroeder Arthritis Institute, University Health Network, Toronto, Ontario, Canada
| | - Christian Veillette
- Department of Orthopaedic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Nizar Mahomed
- Department of Orthopaedic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Y Raja Rampersaud
- Department of Orthopaedic Surgery, University Health Network, Toronto, Ontario, Canada
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Williams AR, Mauro CM, Feng T, Waples J, Martins SS, Haney M. Adult Medical Cannabinoid Use and Changes in Prescription Controlled Substance Use. Cannabis Cannabinoid Res 2023; 8:933-941. [PMID: 35486854 PMCID: PMC10589493 DOI: 10.1089/can.2021.0212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Introduction: Nonopioid-based strategies for managing chronic noncancer pain are needed to help reduce overdose deaths. Although lab studies and population-level data suggest that cannabinoids could provide opioid-sparing effects, among medical cannabis participants they may also impact overdose risk by modifying other controlled substance use such as sedative hypnotics. However, no study has combined observational data at the individual level to empirically address interactions between the use of cannabinoids and prescribed controlled substances. Methods: Electronic health records, including prescription drug monitoring program data, from a large multisite medical cannabis program in New York State were abstracted for all participants with noncancer pain and recently prescribed noncannabinoid controlled substances who completed a new intake visit from April 15, 2018-April 14, 2019 and who remained actively in treatment for >180 days. Participants were partitioned into two samples: those with recent opioid use and those with active opioid use and co-use of sedative hypnotics. A patient-month level analysis assessed total average equivalent milligrams by class of drug (i.e., cannabinoid distinguishing tetrahydrocannabinol [THC] vs. cannabidiol [CBD], opioids, and sedative-hypnotics) received as a time-varying outcome measure across each 30-day "month" period postintake for at least 6 months for all participants. Results: Sample 1 of 285 opioid users were 61.1 years of age (±13.5), 57.5% female, and using an average of 49.7 (±98.5) morphine equivalents daily at intake. Unadjusted analyses found a modest decline in morphine equivalents to 43.9 mg (±94.1 mg) from 49.7 (±98.5) in month 1 (p=0.047) while receiving relatively low doses of THC (2.93 mg/day) and CBD (2.15 mg/day). Sample 2 of 95 opioid and sedative-hypnotic users were 60.9 years of age (±13.1), 63.2% female, and using an average of 86.6 (±136.2) morphine equivalents daily, and an average of 4.3 (±5.6) lorazepam equivalents. Unadjusted analyses did not find significant changes in either morphine equivalents (p=0.81) or lorazepam equivalents (p=0.980), and patients similarly received relatively low doses of THC (2.32 mg/day) and CBD (2.24 mg/day). Conclusions: Findings demonstrated minimal to no change in either opioids or sedative hypnotics over the 6 months of medical cannabis use but may be limited by low retention rates, external generalizability, and an inability to account for nonprescribed substance use.
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Affiliation(s)
- Arthur Robin Williams
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, New York, USA
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Christine M. Mauro
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Tianshu Feng
- Research Foundation for Mental Hygiene, New York, New York, USA
| | - Josef Waples
- City University of New York School of Professional Studies, New York, New York, USA
| | - Silvia S. Martins
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
| | - Margaret Haney
- Research Foundation for Mental Hygiene, New York, New York, USA
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Scheuing WJ, Reginato AM, Deeb M, Acer Kasman S. The burden of osteoarthritis: Is it a rising problem? Best Pract Res Clin Rheumatol 2023; 37:101836. [PMID: 37633827 DOI: 10.1016/j.berh.2023.101836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 04/27/2023] [Indexed: 08/28/2023]
Abstract
The objective of this review is to provide an overview of the current status of osteoarthritis (OA) as one of the most common joint disorders worldwide. Despite being the 11th cause of disability globally, there has been an increase in the prevalence, annual incidence, and years lived with disability of OA, particularly in developed and developing countries. Erosive hand OA, which affects approximately 10% of the general population, has been associated with a higher clinical burden compared to non-erosive hand OA. Patients with knee and hip OA, but not hand OA, are also at an increased risk of cardiovascular disease and all-cause mortality. Furthermore, OA has a significant contribution to healthcare costs in most countries. The recent COVID-19 pandemic has further exacerbated the disease burden of OA patients due to limited access to medical and surgical treatment. With increasing life expectancy and the aging of the global population, the burden of OA is expected to worsen. Therefore, this review highlights the importance of improving population and policymaker awareness of risk factors, such as obesity and injury, as well as early intervention and management of OA to control the future burden of the disease.
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Affiliation(s)
| | | | - Mery Deeb
- Department of Internal Medicine, Kent Hospital/Brown University, Warwick, RI, USA.
| | - Sevtap Acer Kasman
- Marmara University School of Medicine, PMR Department, Rheumatology Division, Istanbul, Türkiye.
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Lupattelli A, Trinh NTH, Nordeng H. Association of maternal personality traits with medication use during pregnancy to appraise unmeasured confounding in long-term pharmacoepidemiological safety studies. Front Pharmacol 2023; 14:1160168. [PMID: 37256227 PMCID: PMC10225644 DOI: 10.3389/fphar.2023.1160168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 04/26/2023] [Indexed: 06/01/2023] Open
Abstract
Maternal personality is a possible confounder on the association between prenatal medication exposure and long-term developmental outcomes in offspring, but it is often unmeasured. This study aimed to (i) estimate the association between five maternal personality traits and prenatal use of acetaminophen (including extended use), opioid analgesics, antidepressants, benzodiazepines/z-hypnotics, and antipsychotics; (ii) evaluate, using an applied example, whether unmeasured confounding by maternal neuroticism would make the association between prenatal antidepressant-child ADHD null, using the E-value framework. We used data from 8,879 pregnant women and recent mothers who participated in the Multinational Medication Use in Pregnancy Study, a web-based cross-sectional study performed within the period from 1-Oct-2011 to 29-Feb-2012 in Europe, North America and Australia. Medication use in pregnancy was self-reported by the women. Personality was assessed with the Big Five Inventory, capturing the dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness. Adjusted logistic regression analyses were conducted for each trait-medication pair, using the survey weighting. There was a strong association between having high neuroticism and prenatal use of antidepressants (Odds Ratio (OR): 5.63, 95% Confidence Interval (CI): 3.96-8.01), benzodiazepines/z-hypnotics (OR: 6.66, 95% CI: 4.05-10.95), and analgesic opioids (OR: 2.24, 95% CI: 1.41-3.56), but not with antipsychotics. Among women with mental illness, this association attenuated for benzodiazepines/z-hypnotics, but decreased to the null for antidepressants. High neuroticism (OR: 1.31, 95% CI: 1.08-1.59) and high openness (OR: 0.77, 95% CI: 0.64-0.93) were associated with extended use of acetaminophen. The E-value for the Hazard Ratio 1.93 in the applied example was 3.27. If the example study was conducted using a population comparison group, high maternal neuroticism could have explained away the association antidepressant-ADHD. Because the example study included only women with a mental illness, this risk of bias was assessed as minimal. Various personality dispositions in the mother are associated, with a different degree, to prenatal use of medication. The strength of these association can aid researchers in evaluating the influence of uncontrolled confounding by maternal personality in long-term safety studies in pregnancy, using the E-value. This assessment should always be performed in addition to a rigorous study design using approaches to triangulate the evidence.
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Affiliation(s)
- Angela Lupattelli
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Nhung T. H. Trinh
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Hedvig Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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10
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Gupta S, Dhawan A, Dhawan J, McColl MA, Smith KM, McColl A. Potentially harmful drug-drug interactions in the therapeutic regimens of persons with spinal cord injury. J Spinal Cord Med 2023:1-9. [PMID: 36972222 DOI: 10.1080/10790268.2023.2185399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVES Individuals with spinal cord injury deal with multiple health complications that require them to use many medications. The purpose of this paper was to find the most common potentially harmful drug-drug interactions (DDIs) in therapeutic regimens of persons with spinal cord injury, and the risk factors associated with it. We further highlight the relevance of each of the DDIs specific to spinal cord injury population. DESIGN Observational design and cross-sectional analysis. SETTING Community; Canada. PARTICIPANTS Individuals with spinal cord injury (n = 108). MAIN OUTCOME MEASURES/ANALYSIS The main outcome was the presence of one or more potential DDIs that can lead to an adverse outcome. All the reported drugs were classified as per the World Health Organization's Anatomical Therapeutic Chemical Classification system. Twenty potential DDIs were selected for the analysis based on the most common medications prescribed to people with spinal cord injury and severity of clinical consequences. The medication lists of study participants were analyzed for selected DDIs. RESULTS Among the 20 potential DDIs analyzed in our sample, the top 3 prevalent DDIs were Opioids + Skeletal Muscle Relaxants, Opioids + Gabapentinoids, and Benzodiazepines + ≥ 2 other central nervous system (CNS)-active drugs. Of the total sample of 108 respondents, 31 participants (29%) were identified with having at least one potential DDI. The risk of having a potential DDI was highly associated with polypharmacy, though no associations were found between the presence of a drug interaction and age, sex, level of injury, time since injury, or cause of injury among the study sample. CONCLUSION Almost three out of ten individuals with spinal cord injury were at risk of having a potentially harmful drug interaction. Clinical and communication tools are needed that facilitate identification and elimination of harmful drug combinations in the therapeutic regimens of patients with spinal cord injury.
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Affiliation(s)
- Shikha Gupta
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Alaina Dhawan
- Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Jillian Dhawan
- Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Mary Ann McColl
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Karen M Smith
- Department of Physical Medicine and Rehabilitation, School of Medicine, Queen's University, Kingston, Canada
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Marcelo AC, Ho EK, Hunter DJ, Hilmer SN, Jokanovic N, Prior J, Carvalho-E-Silva AP, Ferreira ML. TANGO: Development of Consumer Information Leaflets to Support TAperiNG of Opioids in Older Adults with Low Back Pain and Hip and Knee Osteoarthritis. Drugs Aging 2023; 40:343-354. [PMID: 36972011 PMCID: PMC10040925 DOI: 10.1007/s40266-023-01011-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Globally, the rate of opioid prescription is high for chronic musculoskeletal conditions despite guidelines recommending against their use as their adverse effects outweigh their modest benefit. Deprescribing opioids is a complex process that can be hindered by multiple prescriber- and patient-related barriers. These include fear of the process of, or outcomes from, weaning medications, or a lack of ongoing support. Thus, involving patients, their carers, and healthcare professionals (HCPs) in the development of consumer materials that can educate and provide support for patients and HCPs over the deprescribing process is critical to ensure that the resources have high readability, usability, and acceptability to the population of interest. OBJECTIVE This study aimed to (1) develop two educational consumer leaflets to support opioid tapering in older people with low back pain (LBP) and hip or knee osteoarthritis (HoKOA), and (2) evaluate the perceived usability, acceptability, and credibility of the consumer leaflets from the perspective of consumers and HCPs. DESIGN This was an observational survey involving a consumer review panel and an HCP review panel. PARTICIPANTS 30 consumers (and/or their carers) and 20 HCPs were included in the study. Consumers were people older than 65 years of age who were currently experiencing LBP or HoKOA, and with no HCP background. Carers were people who provided unpaid care, support, or assistance to an individual meeting the inclusion criteria for consumers. HCPs included physiotherapists (n = 9), pharmacists (n = 7), an orthopaedic surgeon (n = 1), a rheumatologist (n = 1), nurse practitioner (n = 1) and a general practitioner (n = 1), all with at least three years of clinical experience and who reported working closely with this target patient population within the last 12 months. METHODS Prototypes of two educational consumer leaflets (a brochure and a personal plan) were developed by a team of LBP, OA, and geriatric pharmacotherapy researchers and clinicians. The leaflet prototypes were evaluated by two separate chronological review panels involving (1) consumers and/or their carers, and (2) HCPs. Data collection for both panels occurred via an online survey. Outcomes were the perceived usability, acceptability, and credibility of the consumer leaflets. Feedback received from the consumer panel was used to refine the leaflets, before circulating the leaflets for further review by the HCP panel. Additional feedback from the HCP review panel was then used to refine the final versions of the consumer leaflets. RESULTS Both consumers and HCPs perceived the leaflets and personal plan to be usable, acceptable, and credible. Consumers rated the brochure against several categories, which scored between 53 and 97% positive responses. Similarly, the overall feedback provided by HCPs was 85-100% positive. The modified System Usability Scale scores obtained from HCPs was 55-95% positive, indicating excellent usability. Feedback for the personal plan from both HCPs and consumers was largely positive, with consumers providing the highest positive ratings (80-93%). While feedback for HCPs was also high, we did identify that prescribers were hesitant to provide the plan to patients frequently (no positive responses). CONCLUSIONS This study led to the development of a leaflet and personal plan to support the reduction of opioid use in older people with LBP or HoKOA. The development of the consumer leaflets incorporated feedback provided by HCPs and consumers to maximise clinical effectiveness and future intervention implementation.
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Affiliation(s)
- Alessandra C Marcelo
- The University of Sydney, Sydney Musculoskeletal Health and Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Level 10, Kolling Building, Gamaragal Country, St Leonards, Sydney, NSW, 2065, Australia.
| | - Emma K Ho
- The University of Sydney, Sydney Musculoskeletal Health and Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Level 10, Kolling Building, Gamaragal Country, St Leonards, Sydney, NSW, 2065, Australia
- The University of Sydney, Sydney Musculoskeletal Health, Charles Perkins Centre, Faculty of Medicine and Health, School of Health Sciences, University of Sydney, Eora Country, Sydney, NSW, Australia
| | - David J Hunter
- The University of Sydney, Sydney Musculoskeletal Health and Kolling Institute, School of Medicine, Faculty of Medicine and Health, University of Sydney and the Rheumatology Department, Northern Sydney Local Health District, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Kolling Institute, Laboratory of Ageing and Pharmacology, The University of Sydney and Northern Sydney Local Health District, Reserve Road, Sydney, NSW, 2065, Australia
| | - Natali Jokanovic
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Joanna Prior
- The University of Sydney, Sydney Musculoskeletal Health and Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Level 10, Kolling Building, Gamaragal Country, St Leonards, Sydney, NSW, 2065, Australia
| | - Ana Paula Carvalho-E-Silva
- The University of Sydney, Sydney Musculoskeletal Health and John Walsh Centre for Rehabilitation Research, Sydney Medical School Northern, The University of Sydney, Sydney, NSW, Australia
| | - Manuela L Ferreira
- The University of Sydney, Sydney Musculoskeletal Health and Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, The University of Sydney and the Northern Sydney Local Health District, Level 10, Kolling Building, Gamaragal Country, St Leonards, Sydney, NSW, 2065, Australia
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12
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Acharya M, Hayes CJ, Li C, Painter JT, Dayer L, Martin BC. Comparative Study of Opioid Initiation With Tramadol, Short-acting Hydrocodone, or Short-acting Oxycodone on Opioid-related Adverse Outcomes Among Chronic Noncancer Pain Patients. Clin J Pain 2023; 39:107-118. [PMID: 36728675 PMCID: PMC10210068 DOI: 10.1097/ajp.0000000000001093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 12/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the safety profiles of low and high-dose tramadol, short-acting hydrocodone, and short-acting oxycodone therapies among chronic noncancer pain individuals. MATERIALS AND METHODS A retrospective cohort study of individuals with back/neck pain/osteoarthritis with an initial opioid prescription for tramadol, hydrocodone, or oxycodone was conducted using IQVIA PharMetrics Plus claims for Academics database (2006 to 2020). Two cohorts were created for separately studying opioid-related adverse events (overdoses, accidents, self-inflicted injuries, and violence-related injuries) and substance use disorders (opioid and nonopioid). Patients were followed from the index date until an outcome event, end of enrollment, or data end. Time-varying exposure groups were constructed and Cox regression models were estimated. RESULTS A total of 1,062,167 (tramadol [16.5%], hydrocodone [61.1%], and oxycodone [22.4%]) and 986,809 (tramadol [16.5%], hydrocodone [61.3%], and oxycodone [22.2%]) individuals were in the adverse event and substance use disorder cohorts. All high-dose groups had elevated risk of nearly all outcomes, compared with low-dose hydrocodone. Compared with low-dose hydrocodone, low-dose oxycodone was associated with a higher risk of opioid overdose (hazard ratio: 1.79 [1.37 to 2.33]). No difference in risk was observed between low-dose tramadol and low-dose hydrocodone (hazard ratio: 0.85 [0.64 to 1.13]). Low-dose oxycodone had higher risks of an opioid use disorder, and low-dose tramadol had a lower risk of accidents, self-inflicted injuries, and opioid use disorder compared with low-dose hydrocodone. DISCUSSION Low-dose oxycodone had a higher risk of opioid-related adverse outcomes compared with low-dose tramadol and hydrocodone. This should be interpreted in conjunction with the benefits of pain control and functioning associated with oxycodone use in future research.
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Affiliation(s)
| | - Corey J Hayes
- Department of Biomedical Informatics, College of Medicine
- Center for Mental Health Care and Outcomes Research, Central Arkansas Veterans Health Care Systems, North Little Rock, AR
| | - Chenghui Li
- Division of Pharmaceutical Evaluation and Policy
| | | | - Lindsey Dayer
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock
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13
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Greenwald MK, Moses TEH, Lundahl LH, Roehrs TA. Anhedonia modulates benzodiazepine and opioid demand among persons in treatment for opioid use disorder. Front Psychiatry 2023; 14:1103739. [PMID: 36741122 PMCID: PMC9892948 DOI: 10.3389/fpsyt.2023.1103739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/02/2023] [Indexed: 01/20/2023] Open
Abstract
Background Benzodiazepine (BZD) misuse is a significant public health problem, particularly in conjunction with opioid use, due to increased risks of overdose and death. One putative mechanism underlying BZD misuse is affective dysregulation, via exaggerated negative affect (e.g., anxiety, depression, stress-reactivity) and/or impaired positive affect (anhedonia). Similar to other misused substances, BZD consumption is sensitive to price and individual differences. Although purchase tasks and demand curve analysis can shed light on determinants of substance use, few studies have examined BZD demand, nor factors related to demand. Methods This ongoing study is examining simulated economic demand for alprazolam (among BZD lifetime misusers based on self-report and DSM-5 diagnosis; n = 23 total; 14 male, 9 female) and each participant's preferred-opioid/route using hypothetical purchase tasks among patients with opioid use disorder (n = 59 total; 38 male, 21 female) who are not clinically stable, i.e., defined as being early in treatment or in treatment longer but with recent substance use. Aims are to determine whether: (1) BZD misusers differ from never-misusers on preferred-opioid economic demand, affective dysregulation (using questionnaire and performance measures), insomnia/behavioral alertness, psychiatric diagnoses or medications, or urinalysis results; and (2) alprazolam demand among BZD misusers is related to affective dysregulation or other measures. Results Lifetime BZD misuse is significantly (p < 0.05) related to current major depressive disorder diagnosis, opioid-negative and methadone-negative urinalysis, higher trait anxiety, greater self-reported affective dysregulation, and younger age, but not preferred-opioid demand or insomnia/behavioral alertness. Alprazolam and opioid demand are each significantly positively related to higher anhedonia and, to a lesser extent, depression symptoms but no other measures of negative-affective dysregulation, psychiatric conditions or medications (including opioid agonist therapy or inpatient/outpatient treatment modality), or sleep-related problems. Conclusion Anhedonia (positive-affective deficit) robustly predicted increased BZD and opioid demand; these factors could modulate treatment response. Routine assessment and effective treatment of anhedonia in populations with concurrent opioid and sedative use disorder may improve treatment outcomes. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT03696017, identifier NCT03696017.
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Affiliation(s)
- Mark K. Greenwald
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Tabitha E. H. Moses
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Leslie H. Lundahl
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
| | - Timothy A. Roehrs
- Substance Abuse Research Division, Department of Psychiatry and Behavioral Neurosciences, School of Medicine, Wayne State University, Detroit, MI, United States
- Sleep Disorders Center, Henry Ford Health System, Detroit, MI, United States
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Development of a Clinical Prediction Rule for Treatment Success with Transcranial Direct Current Stimulation for Knee Osteoarthritis Pain: A Secondary Analysis of a Double-Blind Randomized Controlled Trial. Biomedicines 2022; 11:biomedicines11010004. [PMID: 36672512 PMCID: PMC9855334 DOI: 10.3390/biomedicines11010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
The study’s objective was to develop a clinical prediction rule that predicts a clinically significant analgesic effect on chronic knee osteoarthritis pain after transcranial direct current stimulation treatment. This is a secondary analysis from a double-blind randomized controlled trial. Data from 51 individuals with chronic knee osteoarthritis pain and an impaired descending pain inhibitory system were used. The intervention comprised a 15-session protocol of anodal primary motor cortex transcranial direct current stimulation. Treatment success was defined by the Western Ontario and McMaster Universities’ Osteoarthritis Index pain subscale. Accuracy statistics were calculated for each potential predictor and for the final model. The final logistic regression model was statistically significant (p < 0.01) and comprised five physical and psychosocial predictor variables that together yielded a positive likelihood ratio of 14.40 (95% CI: 3.66−56.69) and an 85% (95%CI: 60−96%) post-test probability of success. This is the first clinical prediction rule proposed for transcranial direct current stimulation in patients with chronic pain. The model underscores the importance of both physical and psychosocial factors as predictors of the analgesic response to transcranial direct current stimulation treatment. Validation of the proposed clinical prediction rule should be performed in other datasets.
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15
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Linnet K, Thorsteinsdottir HS, Sigurdsson JA, Sigurdsson EL, Gudmundsson LS. Co-prescribing of opioids and benzodiazepines/Z-drugs associated with all-cause mortality—A population-based longitudinal study in primary care with weak opioids most commonly prescribed. Front Pharmacol 2022; 13:932380. [PMID: 36147347 PMCID: PMC9485885 DOI: 10.3389/fphar.2022.932380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/16/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction: The risk of mortality associated with the co-prescribing of benzodiazepines and opioids has been explored in a number of papers mainly focusing on strong opioids. The mortality risk associated with the use of weak opioids has not been dealt with to a similar extent. Objective: To assess the mortality risk in primary care patients with consistent 3-year co-prescribing of benzodiazepine/Z-drugs (benzodiazepine receptor modulators) and mainly weak opioids (codeine, tramadol). Methods: Of 221,804 patients contacting the primary healthcare centres, 124,436 were selected for further analysis, 88,832 participants fulfilled the inclusion criteria, aged 10–69 years and were divided into four groups with neither any use of benzodiazepines/Z-drugs nor opioids as Group 1, 3 years’ use of opioids and no/minimal benzodiazepines/Z-drugs as Group 2, with benzodiazepines/Z-drugs and no/minimal opioids as Group 3, and finally both benzodiazepines/Z-drugs and opioids as Group 4. Hazard ratios were calculated with the no-drug group as a reference, using Cox proportional hazards regression model adjusted for age, sex, number of chronic conditions and cancer patients excluded (n = 87,314). Results: Hazard ratios for mortality increased both in Group 3 where it was 2.66 (95% CI 2.25–3.09) and in Group 4 where it was 5.12 (95% CI 4.25–6.17), with increased dose and higher number of chronic conditions. In Group 4 an opioid dose-dependent increase in mortality among persons using >1000 DDDs benzodiazepines/Z-drugs was observed when those on less than ≤300 DDDs of opioids with HR 4.94 (95% CI 3.54–6.88) were compared to those on >300 DDDs with HR 7.61/95% CI 6.08–9.55). This increase in mortality was not observed among patients on <1000 DDDs of benzodiazepines/Z-drugs. Conclusion: The study supports evidence suggesting that mortality increases in a dose-dependent manner in patients co-prescribed benzodiazepines/Z-drugs and weak opioids (codeine, tramadol). An association between the number of chronic conditions and a rise in mortality was found. Long-term use of these drugs should preferably be avoided. Non-pharmacological therapy should be seriously considered instead of long-term use of benzodiazepines/Z-drugs, and deprescribing implemented for chronic users of these drugs when possible.
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Affiliation(s)
- Kristjan Linnet
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
- *Correspondence: Kristjan Linnet,
| | | | - Johann Agust Sigurdsson
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
- General Practice Research Unit, Department of Public Health and Nursing, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Emil Larus Sigurdsson
- Development Centre for Primary Healthcare in Iceland, Primary Health Care of the Capital Area, Reykjavik, Iceland
- Department of Family Medicine, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
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16
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Rodríguez-Espinosa S, Coloma-Carmona A, Pérez-Carbonell A, Román-Quiles JF, Carballo JL. Differential Experience of Interdose Withdrawal During Long-Term Opioid Therapy and its Association With Patient and Treatment Characteristics: A Latent Class Analysis in Chronic Pain Population. THE JOURNAL OF PAIN 2022; 23:1427-1436. [PMID: 35429674 DOI: 10.1016/j.jpain.2022.03.236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/20/2022] [Accepted: 03/12/2022] [Indexed: 06/14/2023]
Abstract
Opioid withdrawal is characterized by a set of physical and psychological symptoms that depend on both opioid and patient specific characteristics. The present study aims to identify different latent classes of chronic pain patients according to the type of opioid withdrawal symptoms experienced, and to analyze the relationships between the classes and demographic, opioid therapy, psychological and substance use variables. This cross-sectional descriptive study included 391 chronic pain patients on long-term opioid therapy. A Latent Class Analysis (LCA) identified 3 classes (BIC = 7051.89, entropy = .87, LRTs P < .01). The mild withdrawal class showed low probabilities of presenting physical and psychological symptoms, the moderate withdrawal class was characterized by experiencing psychological symptoms, and the severe withdrawal class stood out for high probabilities of presenting both types of symptoms. The classes differed from each other, with higher rates of moderate-severe POUD, opioid misuse, anxiety, depression, and greater pain intensity and interference in more severe withdrawal classes (P < .05). The multinomial logistic regression showed that moderate-severe POUD and anxiety were the strongest variables related to moderate (ORPOUD = 3.34, ORAnxiety = 2.58) and severe withdrawal classes (ORPOUD = 4.26, ORAnxiety = 5.15). Considering that POUD and anxiety were strongly related to a more severe withdrawal syndrome, the inclusion of psychological interventions in pain management seems critical in this population. PERSPECTIVE: Although interdose opioid withdrawal is common in chronic pain patients, this study shows 3 different patterns in its experience (mild, moderate, and severe withdrawal). A more severe withdrawal may result in reduced effectiveness of opioids in relieving pain and increased negative consequences, such as higher risk of POUD. Findings that could help improve chronic pain management.
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Affiliation(s)
- Sara Rodríguez-Espinosa
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, Elche, Spain
| | - Ainhoa Coloma-Carmona
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, Elche, Spain
| | | | | | - José L Carballo
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, Elche, Spain.
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Vina ER, Tsoukas PH, Abdollahi S, Mody N, Roth SC, Redford AH, Kwoh CK. Racial and ethnic differences in the pharmacologic management of osteoarthritis: rapid systematic review. Ther Adv Musculoskelet Dis 2022; 14:1759720X221105011. [PMID: 35794906 PMCID: PMC9251972 DOI: 10.1177/1759720x221105011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background Racial and ethnic disparities in osteoarthritis (OA) patients' disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments. Objectives The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA. Data sources and methods A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for OA. However, compared to non-Hispanic Whites with OA, African Americans and Hispanics with OA were less likely to receive a prescription for cyclooxygenase-2-selective NSAIDs and less likely to report the use of joint health supplements (i.e. glucosamine and chondroitin sulfate). There were minimal/no significant race/ethnic differences in the patient-reported use of the following OA therapies: acetaminophen, opioids, and other complementary/alternative medicines (vitamins, minerals, and herbs). There were also no significant race differences in the receipt of intra-articular therapies (i.e. glucocorticoid or hyaluronic acid). However, there is limited evidence to suggest that African Americans may be less likely than Whites to receive opioids and intra-articular therapies in some OA patient populations. Conclusion This systematic review provides an overview of the current pharmacologic options for OA, with a focus on race and ethnic differences in the use of such medical therapies.
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Affiliation(s)
- Ernest R Vina
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, 201 MOB, 3322 N. Broad Street, Philadelphia, PA 19140, USA
| | - Philip H Tsoukas
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Shahrzad Abdollahi
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Nidhi Mody
- Section of Rheumatology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Stephanie C Roth
- Health Sciences Library, Temple University, Philadelphia, PA, USA
| | - Albert H Redford
- The University of Arizona Arthritis Center and Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - C Kent Kwoh
- The University of Arizona Arthritis Center and Division of Rheumatology, College of Medicine, University of Arizona, Tucson, AZ, USA
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Mannes ZL, Hasin DS, Abdallah AB, Cottler LB. Co-Use of Opioids and Sedatives Among Retired National Football League Athletes. Clin J Sport Med 2022; 32:322-328. [PMID: 35470340 PMCID: PMC9043466 DOI: 10.1097/jsm.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 11/01/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Among the general population, co-use of opioids and sedatives is associated with greater risk of overdose compared with opioid use alone. National Football League (NFL) retirees experience higher rates of opioid use than the general population, although little is known about their co-use with sedatives. The aim of this study was to examine the prevalence and risk factors of opioid and sedative co-use among NFL retirees. DESIGN Retrospective cohort study. SETTING Professional American football. PARTICIPANTS NFL retirees (N = 644). INDEPENDENT VARIABLES Self-reported concussions, pain intensity, heavy alcohol use, physical and mental health impairment, disability status. MAIN OUTCOME MEASURE Any past 30-day co-use of opioids and sedatives. RESULTS Approximately 4.9% of the sample reported past 30-day co-use of opioids and sedatives, although nearly 30% of retirees using opioids also used sedatives. Greater pain was associated with co-use of opioids and sedatives (adjusted odds ratios [aOR] = 1.58; 95% confidence interval [CI] = 1.23-1.98), although retirees with moderate/severe mental health impairment (vs none/mild; aOR = 2.47; 95% CI = 1.04-5.91) and disability (vs no disability; aOR = 1.35; 95% CI = 1.05-1.73) demonstrated greater odds of co-use compared with retirees not using either substance. CONCLUSIONS Given the high rate of sedative use among participants also using opioids, NFL retirees may be susceptible to the negative health consequences associated with co-use. Interventions focused on improving pain and mental health may be especially effective for reducing co-use of these substances among NFL retirees.
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Affiliation(s)
- Zachary L. Mannes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
| | - Deborah S. Hasin
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
- New York State Psychiatric Institute, New York, NY, USA
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Arbi Ben Abdallah
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63108, USA
| | - Linda B. Cottler
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL, USA
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Beresford L, Norwood T. The Effect of Mobile Care Delivery on Clinically Meaningful Outcomes, Satisfaction, and Engagement Among Physical Therapy Patients: Observational Retrospective Study. JMIR Rehabil Assist Technol 2022; 9:e31349. [PMID: 35107436 PMCID: PMC8851343 DOI: 10.2196/31349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 11/23/2021] [Accepted: 12/23/2021] [Indexed: 12/29/2022] Open
Abstract
Background Musculoskeletal care is now delivered via mobile apps as a health care benefit. Although preliminary evidence shows that the clinical outcomes of mobile musculoskeletal care are comparable with those of in-person care, no research has examined the features of app-based care that secure these outcomes. Objective Drawing on the literature around in-person physical therapy, this study examines how patient-provider relationships and program engagement in app-based physical therapy affect clinically meaningful improvements in pain, function, and patient satisfaction. It then evaluates the effects of patient-provider relationships forged through in-app messages or video visits and timely, direct access to care on patients’ engagement in their recovery. Methods We conducted an observational, retrospective study of 814 pre- and postsurveyed participants enrolled in a mobile app physical therapy program where physical therapists prescribed workouts, education, and therapeutic activities after a video evaluation from February 2019 to December 2020. We estimated generalized linear models with logit functions to evaluate the effect of program engagement on clinical outcomes, minimal clinically important differences (MCIDs) in pain (ΔVisual Analogue Scale ≤−1.5) and function (ΔPatient Specific Functional Scale ≥1.3), and the effects of patient-provider relationships and clinical outcomes on patient satisfaction—participant reported likelihood to recommend the program (Net Promoter Scores of 9-10). We estimated Poisson generalized linear models to evaluate the effects of stronger patient-provider relationships and timely access to physical therapy within 24 hours on engagement including the number of weekly workouts and weeks in the program. Results The odds that participants (N=814) had a pain MCID increased by 13% (odds ratio [OR] 1.13, 95% CI 1.04-1.23; P=.003) with each weekly workout and the odds of a function MCID by 4% (OR 1.04, 95% CI 1.00-1.08; P=.03) with each week in the program. Participants with MCIDs in function and large changes in pain (Δ Visual Analogue Scale ≤−3.5) were 1.85 (95% CI 1.17-2.93; P=.01) and 2.84 times (95% CI 1.68-4.78; P<.001) more satisfied, respectively. Those with video follow-up visits were 2 to 3 times (P=.01) more satisfied. Each physical therapist’s message increased weekly workouts by 11% (OR 1.11, 95% CI 1.07-1.16; P<.001). Video follow-up visits increased weekly workouts by at least 16% (OR 1.16, 95% CI 1.04-1.29; P=.01) and weeks in the program at least 8% (OR 1.08, 95% CI 1.01-1.14; P=.02). Access was associated with a 14% increase (OR 1.14, 95% CI 1.05-1.24; P=.003) in weekly workouts. Conclusions Similar to in-person care, program engagement positively affects clinical outcomes, and strong patient-provider relationships positively affect satisfaction. In app-based physical therapy, clinical outcomes positively affect patient satisfaction. Timely access to care and strong patient-provider relationships, particularly those forged through video visits, affect engagement.
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Affiliation(s)
| | - Todd Norwood
- Omada Health Inc, San Francisco, CA, United States
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Beresford L, Norwood T. Can Physical Therapy Deliver Clinically Meaningful Improvements in Pain and Function through a Mobile App?: An Observational Retrospective Study. Arch Rehabil Res Clin Transl 2022; 4:100186. [PMID: 35756979 PMCID: PMC9214340 DOI: 10.1016/j.arrct.2022.100186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objective To examine the effect of digital physical therapy (PT) delivered by mobile application (app) on reducing pain and improving function for people with a variety of musculoskeletal conditions. Design An observational, longitudinal, retrospective study using survey data collected pre- and postdigital PT to estimate multilevel models with random intercepts for patient episodes. Setting Privately insured employees participating in app-based PT as an employer health care benefit. Participants The study sample included 814 participants (N=814) 18 years or older who completed their digital PT program with reported final clinical outcomes between February 2019 (program launch) through December 2020. Mean age of the sample at baseline was 40.9±11.89 years, 47.5% were female, 21% sought care for lower back pain, 16% for shoulders, 15% for knees, and 13% for neck. Interventions Digital PT consisted of a synchronous video evaluation with a physical therapist followed by a course of PT delivered through a mobile app. Main Outcome Measures Pain was measured by the visual analog scale from 0 “no pain” to 10 “worst pain imaginable” and physical function by the Patient-Specific Functional Scale on a scale from 0 “completely unable to perform” to 10 “able to perform normally.” Results After controlling for significant demographics, comorbid conditions, adverse symptoms, chronicity, and severity, the results from multilevel random intercept models showed decreased pain (−2.69 points; 95% CI, −2.86 to −2.53; P<.001) and increased physical function (+2.67 points; 95% CI, 2.45-2.89; P<.001) after treatment. Conclusions Digital PT was associated with clinically meaningful improvements in pain and function among a diverse set of participants. These early data are an encouraging indicator of the clinical benefit of digital PT.
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Oueini R, Goodin AJ, Hincapie-Castillo JM, Vouri SM. Co-utilization of opioids and nonbenzodiazepine hypnotic drugs in U.S. ambulatory care visits, 2006-2016. J Am Pharm Assoc (2003) 2021; 62:468-474.e2. [PMID: 34799261 DOI: 10.1016/j.japh.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/30/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE(S) This study aimed to characterize the co-utilization of non-benzodiazepine sedative 'Z'-drugs with opioids at ambulatory care visits in the United States. DESIGN A cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2016 was completed. SETTING AND PARTICIPANTS Ambulatory care visits in the United States involving adult patients with an opioid prescription were included in the analysis. OUTCOME MEASURES The primary outcome was initiation or continuation of a Z-drug (zolpidem, eszopiclone, or zaleplon) in a patient visit in conjunction with an opioid medication. RESULTS The authors analyzed 564,090,296 visits (weighted from a sample of 28,773) with a reported opioid prescription. Co-utilization of opioids with Z-drugs fluctuated during the study period beginning at 4.0% in 2006 (95% CI 2.2%-5.7%), 6.3% in 2012 (3.7%-8.9%), and 4.7% in 2016 (2.8%-6.5%). Among all opioid visits in the study period, co-utilization with a Z-drug was not significantly different among female patients compared with male patients (5.26% vs. 4.63%, P = 0.26). Among visits with concomitant opioid and Z-drugs, 7.0% reported new initiation of both medications in the same visit. CONCLUSION At ambulatory care visits between 2006 and 2016, co-utilization of opioids and Z-drugs fluctuated with some differences by sex. Major regulatory advisories and policy changes during this period may have contributed to these varying rates of utilization. Additional work is needed to identify predictors of co-utilization and downstream consequences more widely.
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da Costa BR, Pereira TV, Saadat P, Rudnicki M, Iskander SM, Bodmer NS, Bobos P, Gao L, Kiyomoto HD, Montezuma T, Almeida MO, Cheng PS, Hincapié CA, Hari R, Sutton AJ, Tugwell P, Hawker GA, Jüni P. Effectiveness and safety of non-steroidal anti-inflammatory drugs and opioid treatment for knee and hip osteoarthritis: network meta-analysis. BMJ 2021; 375:n2321. [PMID: 34642179 PMCID: PMC8506236 DOI: 10.1136/bmj.n2321] [Citation(s) in RCA: 88] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the effectiveness and safety of different preparations and doses of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and paracetamol for knee and hip osteoarthritis pain and physical function to enable effective and safe use of these drugs at their lowest possible dose. DESIGN Systematic review and network meta-analysis of randomised trials. DATA SOURCES Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, regulatory agency websites, and ClinicalTrials.gov from inception to 28 June 2021. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised trials published in English with ≥100 patients per group that evaluated NSAIDs, opioids, or paracetamol (acetaminophen) to treat osteoarthritis. OUTCOMES AND MEASURES The prespecified primary outcome was pain. Physical function and safety outcomes were also assessed. REVIEW METHODS Two reviewers independently extracted outcomes data and evaluated the risk of bias of included trials. Bayesian random effects models were used for network meta-analysis of all analyses. Effect estimates are comparisons between active treatments and oral placebo. RESULTS 192 trials comprising 102 829 participants examined 90 different active preparations or doses (68 for NSAIDs, 19 for opioids, and three for paracetamol). Five oral preparations (diclofenac 150 mg/day, etoricoxib 60 and 90 mg/day, and rofecoxib 25 and 50 mg/day) had ≥99% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. Topical diclofenac (70-81 and 140-160 mg/day) had ≥92.3% probability, and all opioids had ≤53% probability of more pronounced treatment effects than the minimal clinically relevant reduction in pain. 18.5%, 0%, and 83.3% of the oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of dropouts due to adverse events. 29.8%, 0%, and 89.5% of oral NSAIDs, topical NSAIDs, and opioids, respectively, had an increased risk of any adverse event. Oxymorphone 80 mg/day had the highest risk of dropouts due to adverse events (51%) and any adverse event (88%). CONCLUSIONS Etoricoxib 60 mg/day and diclofenac 150 mg/day seem to be the most effective oral NSAIDs for pain and function in patients with osteoarthritis. However, these treatments are probably not appropriate for patients with comorbidities or for long term use because of the slight increase in the risk of adverse events. Additionally, an increased risk of dropping out due to adverse events was found for diclofenac 150 mg/day. Topical diclofenac 70-81 mg/day seems to be effective and generally safer because of reduced systemic exposure and lower dose, and should be considered as first line pharmacological treatment for knee osteoarthritis. The clinical benefit of opioid treatment, regardless of preparation or dose, does not outweigh the harm it might cause in patients with osteoarthritis. SYSTEMATIC REVIEW REGISTRATION PROSPERO number CRD42020213656.
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Affiliation(s)
- Bruno R da Costa
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Tiago V Pereira
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Pakeezah Saadat
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Martina Rudnicki
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Ophthalmology, University College London, London, UK
| | - Samir M Iskander
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Schulich School of Medicine, University of Western Ontario, London, ON, Canada
| | - Nicolas S Bodmer
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Department of Medicine, University of Zurich, Zurich, Switzerland
| | - Pavlos Bobos
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Western's Bone and Joint Institute, Western University, London, ON, Canada
| | - Li Gao
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | | | - Thais Montezuma
- Health Technology Assessment Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
| | - Matheus O Almeida
- Health Technology Assessment Unit, Oswaldo Cruz German Hospital, São Paulo, Brazil
- Master Program in Physical Therapy, Universidade Ibirapuera, São Paulo, Brazil
| | - Pai-Shan Cheng
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Biostatistics Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cesar A Hincapié
- Department of Chiropractic Medicine, Faculty of Medicine, University of Zurich and Balgrist University Hospital, Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, Zurich, Switzerland
| | - Roman Hari
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Primary Health Care (BIHAM), University of Bern, Switzerland
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Peter Tugwell
- Department of Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gillian A Hawker
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Jüni
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Jin MC, Ho AL, Feng AY, Zhang Y, Staartjes VE, Stienen MN, Han SS, Veeravagu A, Ratliff JK, Desai AM. Predictive modeling of long-term opioid and benzodiazepine use after intradural tumor resection. Spine J 2021; 21:1687-1699. [PMID: 33065272 DOI: 10.1016/j.spinee.2020.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 08/05/2020] [Accepted: 10/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Despite increased awareness of the ongoing opioid epidemic, opioid and benzodiazepine use remain high after spine surgery. In particular, long-term co-prescription of opioids and benzodiazepines have been linked to high risk of overdose-associated death. Tumor patients represent a unique subset of spine surgery patients and few studies have attempted to develop predictive models to anticipate long-term opioid and benzodiazepine use after spinal tumor resection. METHODS The IBM Watson Health MarketScan Database and Medicare Supplement were assessed to identify admissions for intradural tumor resection between 2007 and 2015. Adult patients were required to have at least 6 months of continuous preadmission baseline data and 12 months of continuous postdischarge follow-up. Primary outcomes were long-term opioid and benzodiazepine use, defined as at least 6 prescriptions within 12 months. Secondary outcomes were durations of opioid and benzodiazepine prescribing. Logistic regression models, with and without regularization, were trained on an 80% training sample and validated on the withheld 20%. RESULTS A total of 1,942 patients were identified. The majority of tumors were extramedullary (74.8%) and benign (62.5%). A minority of patients received arthrodesis (9.2%) and most patients were discharged to home (79.1%). Factors associated with postdischarge opioid use duration include tumor malignancy (vs benign, B=19.8 prescribed-days/year, 95% confidence interval [CI] 1.1-38.5) and intramedullary compartment (vs extramedullary, B=18.1 prescribed-days/year, 95% CI 3.3-32.9). Pre- and perioperative use of prescribed nonsteroidal anti-inflammatory drugs and gabapentin/pregabalin were associated with shorter and longer duration opioid use, respectively. History of opioid and history of benzodiazepine use were both associated with increased postdischarge opioid and benzodiazepine use. Intramedullary location was associated with longer duration postdischarge benzodiazepine use (B=10.3 prescribed-days/year, 95% CI 1.5-19.1). Among assessed models, elastic net regularization demonstrated best predictive performance in the withheld validation cohort when assessing both long-term opioid use (area under curve [AUC]=0.748) and long-term benzodiazepine use (AUC=0.704). Applying our model to the validation set, patients scored as low-risk demonstrated a 4.8% and 2.4% risk of long-term opioid and benzodiazepine use, respectively, compared to 35.2% and 11.1% of high-risk patients. CONCLUSIONS We developed and validated a parsimonious, predictive model to anticipate long-term opioid and benzodiazepine use early after intradural tumor resection, providing physicians opportunities to consider alternative pain management strategies.
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Affiliation(s)
- Michael C Jin
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Austin Y Feng
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Yi Zhang
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Victor E Staartjes
- Machine Intelligence in Clinical Neuroscience (MICN) Laboratory, Clinical Neuroscience Center, University Hospital Zurich, Switzerland; Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Summer S Han
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Atman M Desai
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States.
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Ashraf AJ, Gilbert TA, Holmer HK, Cook LJ, Carlson KF. Receipt of Concurrent VA and Non-VA Opioid and Sedative-Hypnotic Prescriptions Among Post-9/11 Veterans With Traumatic Brain Injury. J Head Trauma Rehabil 2021; 36:364-373. [PMID: 34489387 DOI: 10.1097/htr.0000000000000728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Receipt of concurrent psychotropic prescription medications from both US Department of Veterans Affairs (VA) and non-VA healthcare providers may increase risk of adverse opioid-related outcomes among veterans with traumatic brain injury (TBI). Little is known about patterns of dual-system opioid or sedative-hypnotic prescription receipt in this population. We estimated the prevalence and patterns of, and risk factors for, VA/non-VA prescription overlap among post-9/11 veterans with TBI receiving opioids from VA providers in Oregon. SETTING Oregon VA and non-VA outpatient care. PARTICIPANTS Post-9/11 veterans in Oregon with TBI who received an opioid prescription from VA providers between the years of 2014 and 2019. DESIGN Historical cohort study. MAIN MEASURES Prescription overlap of VA opioids and non-VA opioids or sedative-hypnotics; proportions of veterans who received VA or non-VA opioid, benzodiazepine, and nonbenzodiazepine sedative-hypnotic prescriptions were also examined by year and by veteran characteristics. RESULTS Among 1036 veterans with TBI receiving opioids from the VA, 210 (20.3%) received an overlapping opioid prescription from a non-VA provider; 5.3% received overlapping benzodiazepines; and none received overlapping nonbenzodiazepine sedative-hypnotics. Proportions of veterans with prescription overlap tended to decrease over time. Veterans with other than urban versus urban addresses (OR = 1.4; 95% CI, 1.0-1.8), high versus medium average annual VA visits (OR = 1.7; 95% CI, 1.1-2.6), and VA service connection of 50% or more versus none/0% to 40% (OR = 4.3; 95% CI, 1.3-14.0) were more likely to have concurrent VA/non-VA prescriptions in bivariable analyses; other than urban remained associated with overlap in multivariable models. Similarly, veterans with comorbid posttraumatic stress disorder diagnoses were more likely to have concurrent VA/non-VA prescriptions in both bivariable and multivariable (OR = 2.1; 95% CI, 1.0-4.1) models. CONCLUSION Among post-9/11 veterans with TBI receiving VA opioids, a considerable proportion had overlapping non-VA prescription medications. Providers and healthcare systems should consider all sources of psychotropic prescriptions, and risk factors for overlapping medications, to help mitigate potentially unsafe medication use among veterans with TBI.
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Affiliation(s)
- Alexandria J Ashraf
- VA HSR&D Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health Care System, Portland, Oregon (Mss Ashraf and Gilbert and Drs Holmer and Carlson); Oregon Health & Science University, Portland State University School of Public Health, Portland (Ms Ashraf and Dr Carlson); and Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City (Dr Cook)
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Moran KM, Calip GS, Lee TA, Koronkowski MJ, Lau DT, Schumock GT. Risk of fall-related injury and all-cause hospitalization of select concomitant central nervous system medication prescribing in older adult persistent opioid users: A case-time-control analysis. Pharmacotherapy 2021; 41:733-742. [PMID: 34328644 DOI: 10.1002/phar.2612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/09/2021] [Accepted: 07/09/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Concomitant use of central nervous system (CNS) medications frequently occurs in older adults with persistent opioid use. The risks of adverse outcomes associated with combinations of opioids, sedative hypnotics, or skeletal muscle relaxants have not been sufficiently described in this population. OBJECTIVE To compare the overall and incremental risk of (1) fall-related injury and (2) all-cause hospitalization associated with sedative hypnotics and skeletal muscle relaxants among older persistent opioid users. METHODS A case-time-control study was conducted using administrative claims of adults ages ≥66 years with a history of persistent (≥90 days) opioid use. Cases included those with first (1) emergency department, hospital, or outpatient visit for a fall-related injury, or (2) all-cause hospitalization. Exposure to CNS medications prior to the case event versus earlier periods, and the risk associated with CNS drug class combinations and sequence of use, was estimated using conditional logistic regression, adjusted for time trends and time-varying covariates. RESULTS Among 140,101 older persistent opioid users, 20,723 experienced fall-related injury and 39,444 were hospitalized during follow-up. Skeletal muscle relaxant use was associated with an increased risk of fall-related injury (Odds ratio [OR] 1.28) and all-cause hospitalization (OR 1.11). Statistically significant associations were observed for the joint effects of interactions involving skeletal muscle relaxants on fall-related injury (with opioid: OR 1.25; with sedative hypnotic: OR 1.24), and interactions involving opioids on all-cause hospitalization (with sedative hypnotic: OR 1.10; with skeletal muscle relaxant: OR 1.17). The addition of a skeletal muscle relaxant to an opioid regimen was associated with a 25% increased risk of fall-related injury. Additions of other CNS medications did not have apparent incremental effects on the risk of all-cause hospitalization. CONCLUSION The excess risks of fall-related injury and hospitalization associated with various combinations of CNS medications among older persistent opioid users should be considered in therapeutic decision making. Further research is needed to confirm these findings.
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Affiliation(s)
- Kellyn M Moran
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
- Takeda Pharmaceutical Company Limited, Lexington, Massachusetts, USA
| | - Gregory S Calip
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
- Flatiron Health, New York, New York, USA
| | - Todd A Lee
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Michael J Koronkowski
- College of Pharmacy, Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Denys T Lau
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
- National Committee for Quality Assurance, Washington, District of Columbia, USA
| | - Glen T Schumock
- College of Pharmacy, Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, USA
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Yoo JI, Jang SY, Cha Y, Park CH, Kim JT, Oh S, Choy W. Effect of Opioids on All-cause Mortality and Sustained Opioid Use in Elderly Patients with Hip Fracture: a Korea Nationwide Cohort Study. J Korean Med Sci 2021; 36:e127. [PMID: 34002547 PMCID: PMC8129618 DOI: 10.3346/jkms.2021.36.e127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/06/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The purpose of our study was to assess the use of opioids before and after hip fracture in elderly patients in order to determine the effect of opioid use on all-cause mortality, and to analyze how the history of opioid use before fracture increases the risk of sustained use following hip fracture using a Korea nationwide cohort. METHODS Our study identified hip fracture patients from the Korean National Health Insurance Service-Senior cohort. The index date was defined as 90-days after admission to the acute care hospital that fulfilled the eligibility criteria of elderly hip fracture. Patients were classified into past user, current user, and sustained user according to the use of opioid at each period based on the time of admission and index date. The opioids were classified into strong opioids and tramadol. A generalized estimating equation model with a Poisson distribution and logarithmic link function was performed to estimate the adjusted rate ratios (aRRs) and 95% confidence intervals (CIs) to assess the association between past use and sustained use. A multivariable-adjusted Cox proportional hazard model was used to investigate the effects of strong opioid and tramadol use on all-cause mortality. RESULTS A total of 12,927 patients were included in our study. There were 7,384 (57.12%) opioid past-users, 11,467 (88.71%) opioid current-users, and 7,172 (55.48%) sustained users. In comparison of the death risk according to current use or the defined daily dose of the opioids or past opioid use, there were no significant differences in the adjusted hazard ratio for death in all groups, compared to the current non-users (P > 0.05). Among survivors 1 year after hip fracture, opioid past-use increased the risk of opioid sustained use by 1.52-fold (aRR; 95% CI, 1.45-1.8; P < 0.001). CONCLUSION Current use and past use of opioid did not increase all-cause mortality after hip fracture in elderly patients over 65 years of age. Past use of opioid before hip fracture increased risk of sustained use of opioid compared to the current opioid used without past use.
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Affiliation(s)
- Jun Il Yoo
- Department of Orthopaedic Surgery, Gyeongsang National University Hospital, Jinju, Korea
| | - Suk Yong Jang
- Department of Healthcare Management, Graduate School of Public Health, Yonsei University, Seoul, Korea
| | - Yonghan Cha
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea.
| | - Chan Ho Park
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Daegu, Korea
| | - Jung Taek Kim
- Department of Orthopaedic Surgery, Ajou Medical Center, Suwon, Korea
| | - Seunghak Oh
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
| | - Wonsik Choy
- Department of Orthopaedic Surgery, Eulji University Hospital, Daejeon, Korea
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Opioid prescribing and health outcomes in opioid-naive patients: Analysis of a statewide health information exchange. J Am Pharm Assoc (2003) 2021; 61:623-631.e3. [PMID: 34045156 DOI: 10.1016/j.japh.2021.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/21/2021] [Accepted: 04/27/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Widespread use of prescription opioids is associated with adverse outcomes. OBJECTIVE To identify factors associated with adverse health outcomes and health care use using a statewide health information exchange. METHODS This is a retrospective cohort study using the Indiana Network for Patient Care. Adult opioid-naive patients who received an opioid prescription between January 2012 and December 2017 were included. The outcomes included (1) a composite outcome of any combination of opioid abuse, dependence, or overdose, (2) all-cause mortality, and (3) health care use. Independent variables included opioid dosage, dispensed amount, days supply, concurrent use of short-acting (SA) and long-acting (LA) opioids, and concurrent use with benzodiazepine or gabapentinoids. Additional variables included patients' age, sex, race, modified Charlson Comorbidity Index score, mental health conditions, and medications for opioid use disorders. Factors associated with composite outcome and mortality were identified using Cox proportional hazards and reported as adjusted hazard ratio (aHR) and 95% CI. Factors associated with health care use were identified using Poisson regression and reported as adjusted incidence rate ratio (aIRR) and 95% CI. RESULTS 1,328,287 opioid prescriptions were identified for 341,722 patients. Opioid-related factors associated with the composite outcome, mortality, and hospitalizations, respectively, included opioid dosage (aHR 1.003 [95% CI 1.001-1.006]; aHR not applicable; aIRR 1.07 [1.06-1.08]), opioid days supply (aHR 1.03 [1.02-1.03]; aHR 1.009 [1.005-1.014]; aIRR 0.94 [0.92-0.96]), concurrent SA/LA opioids (aHR 2.12 [1.78-2.54]; aHR 1.40 [1.14-1.70]; aIRR 1.40 [1.37-1.42]), and use of benzodiazepines/gabapentinoids (aHR 1.68 [1.38-2.04]; aHR 1.23 [1.01-1.51]; aIRR 1.25 [1.23-1.27]). CONCLUSION Many factors are associated with poor health outcomes, especially concurrent use of SA and LA opioids and overlapping prescriptions of opioids with benzodiazepines or gabapentinoids. Identification of factors associated with adverse outcomes may help identify patients at risk for poor outcomes and could inform possible interventions.
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Rodríguez-Espinosa S, Coloma-Carmona A, Pérez-Carbonell A, Román-Quiles JF, Carballo JL. Clinical and psychological factors associated with interdose opioid withdrawal in chronic pain population. J Subst Abuse Treat 2021; 129:108386. [PMID: 34080554 DOI: 10.1016/j.jsat.2021.108386] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The DSM-5 diagnostic criteria for Prescription Opioid-Use Disorder (POUD) have undergone some significant changes. One of the most controversial changes has been the elimination of the withdrawal symptoms criterion when opioid use is under appropriate medical supervision. For this reason, the goal of this study was to analyze factors associated with opioid withdrawal in patients with chronic non-cancer pain (CNCP). METHODS This cross-sectional descriptive study involved 404 patients who use prescription opioids for long-term treatment (≥90 days) of CNCP. Measures included sociodemographic and clinical characteristics, POUD, withdrawal symptoms, craving, anxiety-depressive symptoms, and pain intensity and interference. RESULTS Forty-seven percent (n = 193) of the sample reported moderate-severe withdrawal symptoms, which were associated with lower age, higher daily morphine dose and duration of treatment with opioids, moderate-severe POUD, use of psychotropic drugs, higher anxiety-depressive symptoms, and greater pain intensity and interference (p < .05). Binary logistic regression analysis showed that moderate-severe POUD (OR = 2.82), anxiety (OR = 2.21), depression (OR = 1.81), higher pain interference (OR = 1.05), and longer duration of treatment with opioids were the strongest factors associated with moderate-severe withdrawal symptoms (p < .05). CONCLUSION Psychological factors seem to play a key role in the severity of withdrawal symptoms. Since greater intensity of these symptoms increases the risk of developing POUD, knowing the factors associated with withdrawal may be useful in developing preventive psychological interventions.
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Affiliation(s)
- Sara Rodríguez-Espinosa
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202 Elche, Spain
| | - Ainhoa Coloma-Carmona
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202 Elche, Spain
| | - Ana Pérez-Carbonell
- University General Hospital of Elche, Camino de la Almazara, 11, 03203 Elche, Spain
| | - José F Román-Quiles
- University General Hospital of Elche, Camino de la Almazara, 11, 03203 Elche, Spain
| | - José L Carballo
- Center for Applied Psychology, Miguel Hernández University, Avenida Universidad, s/n, 03202 Elche, Spain.
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Black-Tiong S, Gonzalez-Chica D, Stocks N. Trends in long-term opioid prescriptions for musculoskeletal conditions in Australian general practice: a national longitudinal study using MedicineInsight, 2012-2018. BMJ Open 2021; 11:e045418. [PMID: 33827841 PMCID: PMC8031026 DOI: 10.1136/bmjopen-2020-045418] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Describe trends and patterns in long-term opioid prescriptions among adults with musculoskeletal conditions (MSK). DESIGN Interrupted time-series analysis based on an open cohort study. SETTING A representative sample of 402 Australian general practices contributing data to the MedicineInsight database. PARTICIPANTS 811 174 patients aged 18+ years with an MSK diagnosis and three or more consultations in any two consecutive years between 2012 and 2018. Males represented 44.5% of the sample, 28.4% were 65+ years and 1.9% were Aboriginal or Torres Strait Islanders. PRIMARY AND SECONDARY OUTCOME MEASURES Annual prevalence and cumulative incidence (%) of long-term opioid prescribing (3+ prescriptions in 90 days) among patients with an MSK. Average duration of these episodes in each year between 2012 and 2018. RESULTS The prevalence of long-term opioid prescribing increased from 5.5% (95% CI 5.2 to 5.8) in 2012 to 9.1% (95% CI 8.8 to 9.7) in 2018 (annual change OR 1.09, 95% CI 1.08 to 1.09), but a slightly lower incidence was observed in 2018 (3.0% vs 3.6%-3.8% in other years; annual change OR 0.99, 95% CI 0.98 to 0.99). The incidence was between 37% and 52% higher among practices located in rural Australia or lower socioeconomic areas. Individual risk factors included increasing age (3.4 times higher among those aged 80+ years than the 18-34 years group in 2012, increasing to 4.8 times higher in 2018), identifying as Aboriginal or Torres Strait Islander (1.7-1.9 higher incidence than their peers), or living in disadvantaged areas (36%-57% more likely than among those living in wealthiest areas). Long-term opioid prescriptions lasted in average 287-301 days between 2012 and 2016, reducing to 229 days in 2017 and 140 days in 2018. A longer duration was observed in practices from more disadvantaged areas and females in all years, except in 2018. CONCLUSIONS The continued rise in the prevalence of long-term opioid prescribing is of concern, despite a recent reduction in the incidence and duration of opioid management.
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Affiliation(s)
- Sean Black-Tiong
- Discipline of General Practice, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - David Gonzalez-Chica
- Discipline of General Practice, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Adelaide Rural Clinical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nigel Stocks
- Discipline of General Practice, Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
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O'Brien P, Henke RM, Schaefer MB, Lin J, Creedon TB. Adverse events among adult Medicaid enrollees with opioid use disorder and co-occurring substance use disorders. Drug Alcohol Depend 2021; 221:108555. [PMID: 33596496 DOI: 10.1016/j.drugalcdep.2021.108555] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND It is common for adults with opioid use disorder (OUD) to misuse additional substances, and these individuals may be particularly at risk for adverse events, including mortality. Less is known about how continued receipt of prescription opioids or risk of adverse events (e.g., suicidality, overdose, poisoning) differs for people with co-occurring OUD and additional substance use disorders (SUDs). METHODS We conducted a retrospective study using IBM® MarketScan® Multi-State Medicaid Database enrollment/claims data. We used logistic regression to measure the association between sample characteristics and our dependent variables. The sample consisted of non-Medicare-eligible adults aged 18-64 years who were continuously enrolled in Medicaid in 2016-2017 with an OUD diagnosis on at least one claim in 2016. RESULTS Adults with OUD and a co-occurring SUD were more likely than adults with OUD only to have an opioid-related poisoning event (odds ratio [OR] = 1.488, p = .0052), all-cause poisoning (OR = 1.756, p < .0001), or suicidal ideation (OR = 1.796, p < .0001) but not to receive ongoing opioid prescriptions (OR = 0.973, p = .1626). Adverse events varied by OUD-SUD combination. For example, adults with OUD and cocaine use disorder had the highest odds of all-cause (OR = 2.393, p < .0001) or opioid-related (OR = 1.890, p = .0027) poisoning among those with a drug-specific diagnosis and were most likely to be diagnosed with suicidal ideation (OR = 2.465, p < .0001). CONCLUSIONS This study provides evidence that adults with OUD and a co-occurring additional SUD have increased risk for several adverse events. Multisubstance use should be screened for and identified to determine the most appropriate course of treatment.
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Affiliation(s)
- Peggy O'Brien
- IBM Watson Health, 5425 Hollister Avenue, Suite 140, Santa Barbara, CA 93111, USA.
| | | | | | - Janice Lin
- IBM Watson Health, 7700 Old Georgetown Road, Suite 650, Bethesda, MD 20814, USA
| | - Timothy B Creedon
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Cambridge, MA 02141, USA.
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Li L, Chang Y, Song S, Losina E, Costenbader KH, Laidlaw TM. Impact of reported NSAID "allergies" on opioid use disorder in back pain. J Allergy Clin Immunol 2021; 147:1413-1419. [PMID: 32916184 PMCID: PMC7995999 DOI: 10.1016/j.jaci.2020.08.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND It is crucial to identify patients at highest risk for opioid use disorder (OUD) and to address challenges in reducing opioid use. Reported nonsteroidal anti-inflammatory drug (NSAID) allergies may predispose to use of stronger pain medications and potentially to OUD. OBJECTIVE We sought to investigate the clinical impact of reported NSAID allergy on OUD in patients with chronic back pain. METHODS We conducted a retrospective study of adults receiving care at a tertiary health care system from January 1, 2013, to December 31, 2018. Back pain and OUD were identified using administrative data algorithms. We used propensity score matching and logistic regression to estimate the impact of self-reported NSAID adverse drug reactions (ADRs) on risk of OUD, adjusting for other relevant clinical information. RESULTS Of 47,114 patients with chronic back pain, 3,620 (7.7%) had a reported NSAID ADR. In an adjusted propensity score-matched analysis, patients with NSAID ADRs had higher odds (odds ratio, 1.34; 95% CI, 1.07-1.67) of developing OUD as compared with those without NSAID ADRs. Additional risk factors for OUD included younger age, male sex, Medicaid insurance, Medicare insurance, higher number of inpatient and outpatient visits in the previous year, and comorbid anxiety and depression. Patients with listed NSAID ADRs also had higher odds of a documented opioid prescription during the study period (odds ratio, 1.22; 95% CI, 1.11-1.34). CONCLUSIONS Adults with chronic back pain and reported NSAID ADRs are at a higher risk of developing OUD and receiving opioid analgesics, even after accounting for comorbidities and health care utilization. Allergy evaluation is critical for potential delabeling of patients with reported NSAID allergies and chronic pain.
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Affiliation(s)
- Lily Li
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass.
| | - Yuchiao Chang
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, Mass
| | - Shuang Song
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Elena Losina
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Karen H Costenbader
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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Gajda JM, Asiedu M, Morrison G, Dunning JA, Ghoreishi-Haack N, Barth AL. NYX-2925, A NOVEL, NON-OPIOID, SMALL-MOLECULE MODULATOR OF THE N-METHYL-d-ASPARTATE RECEPTOR (NMDAR), DEMONSTRATES POTENTIAL TO TREAT CHRONIC, SUPRASPINAL CENTRALIZED PAIN CONDITIONS. MEDICINE IN DRUG DISCOVERY 2021. [DOI: 10.1016/j.medidd.2020.100067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Vina ER, Quinones C, Hausmann LRM, Ibrahim SA, Kwoh CK. Association of Patients' Familiarity and Perceptions of Efficacy and Risks With the Use of Opioid Medications in the Management of Osteoarthritis. J Rheumatol 2021; 48:1863-1870. [PMID: 33452165 DOI: 10.3899/jrheum.201133] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE While opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA. METHODS A total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients' familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables. RESULTS In this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35.3%), and had higher mean depression (Patient Health Questionnaire [PHQ]-8 7.2 vs 4.9) and OA-related pain (Western Ontario and McMaster Universities Arthritis Index [WOMAC] 54.8 vs 46.8) scores. After adjustment for sociodemographic and clinical variables, the following were associated with opioid medication use: higher perception of medication benefit (OR 1.68, 95% CI 1.18-2.41), lower perception of medication risk (OR 0.67, 95% CI 0.51-0.88), and having family or friends who received the medication for OA (OR 3.88, 95% CI 1.88-8.02). CONCLUSION Among adults with knee/hip OA, opioid use was associated with being familiar with the treatment, as well as believing that the medication was beneficial and low-risk.
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Affiliation(s)
- Ernest R Vina
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Cristian Quinones
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Leslie R M Hausmann
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - Said A Ibrahim
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
| | - C Kent Kwoh
- The current study and ERV were funded in part by the National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) (K23AR067226). CKK's work was supported by the NIH/NIAMS (R01AR066601). SAI was supported in part by a K24 Mid-Career Development Award from NIAMS (K24AR055259). 1E.R. Vina, MD, MS, Associate Professor of Medicine, C.K. Kwoh, MD, Professor of Medicine, Division of Rheumatology, University of Arizona School of Medicine, Tucson, Arizona; 2C.Q. Quinones, BS, University of Arizona Arthritis Center, Tucson, Arizona; 3L.R. Hausmann, PhD, Core Investigator, Veterans Affairs Pittsburgh Healthcare System, and Associate Professor of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 4S. Ibrahim, Professor, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York, USA. The authors declare no conflicts of interest. Address correspondence to Dr. E.R. Vina, University of Arizona Arthritis Center, 1501 N. Campbell Ave., PO Box 245093, Tucson, AZ 85724-5093, USA. . Accepted for publication January 8, 2021
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O'Brien P, Henke RM, Schaefer MB, Lin J, Creedon TB. Utilization of treatment by Medicaid enrollees with opioid use disorder and co-occurring substance use disorders. Drug Alcohol Depend 2020; 217:108261. [PMID: 32979735 DOI: 10.1016/j.drugalcdep.2020.108261] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 07/27/2020] [Accepted: 08/22/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multiple substance use is common among adults who misuse opioids. Adverse consequences of drugs are more severe among multisubstance users than among single drug users. This study sought to determine whether adults with opioid use disorder (OUD) and at least one other substance use disorder (SUD) are less likely than adults with OUD only to receive certain services. METHODS We conducted a retrospective longitudinal study using the IBM® MarketScan® Multi-State Medicaid Database. We used logistic regression to measure associations between clinical characteristics and service utilization. The sample included non-Medicare-eligible adults aged 18-64 years with at least one claim in 2016 with a primary diagnosis of OUD who were continuously enrolled in Medicaid in 2016 and 2017. RESULTS Of the 58,745 Medicaid enrollees with an initial OUD diagnosis in 2016, 29,267 had one or more additional SUD diagnoses. In the year following diagnosis, these adults were less likely than adults with OUD only to receive OUD medication treatment (OR = 0.88, p < .0001). This was true for all specifically diagnosed co-occurring SUDS. Adults with OUD and a co-occurring SUD, however, were more likely than those with OUD only to use any type of high-intensity services. CONCLUSIONS Adults with OUD and at least one co-occurring SUD received more intensive services, which may reflect severity and lack of OUD medication treatment before misuse escalation. Programs should account for barriers to connecting these individuals to appropriate OUD treatment.
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Affiliation(s)
- Peggy O'Brien
- IBM Watson Health, 5425 Hollister Avenue, Suite 140, Santa Barbara, CA 93111, USA.
| | | | | | - Janice Lin
- IBM Watson Health, 7700 Old Georgetown Road, Suite 650, Bethesda, MD 20814, USA.
| | - Timothy B Creedon
- Health Equity Research Lab, Cambridge Health Alliance, 1035 Cambridge Street, Cambridge, MA 02141, USA.
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AlRuthia Y, Alhazzani H, Alhindi G, Alarfaj M, Almutairi L, Alanazi M, Alokili K, Alanazi N, Alodaibi F, Alwhaibi M, Bashatah AS, Asiri Y, Alsanawi H. Predictors of Opioid Prescription Among a Sample of Patients with Acute Musculoskeletal Pain at a Tertiary Care Hospital in Saudi Arabia. J Pain Res 2020; 13:2929-2936. [PMID: 33235491 PMCID: PMC7678505 DOI: 10.2147/jpr.s276630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 10/21/2020] [Indexed: 12/25/2022] Open
Abstract
Background Musculoskeletal pain is one of the most complex and debilitating types of pain. Although different pharmacologic treatments are available, very few studies have explored the predictors for opioid analgesics prescription to manage this type of pain. Objective The aim of this study was to explore the predictors for opioid prescription in patients with acute musculoskeletal pain in Saudi Arabia. Methods This was a single-center, retrospective chart review of adult patients (≥18 yrs.) with an acute nociceptive musculoskeletal pain at a university-affiliated medical center in Riyadh, Saudi Arabia. Cancer patients and those with chronic neuropathic pain were excluded. Patients’ age, gender, number of comorbidities, duration of pain management, number of clinic visits for pain, and Numeric Pain Rating Scale (NPRS) scores at rest and with normal activities were collected. Multiple logistic regression was conducted to examine the relationship between the type of musculoskeletal pain and the prescription of opioid analgesics controlling for NPRS score on activity, age, gender, number of comorbidities, duration of pain treatment, and number of clinic visits for pain. Results The mean age of the 227 patients, who met the inclusion criteria, was 39 years and 68% of them were male. Sixty-three percent of the patients were prescribed opioid analgesics, and 61% of them had shoulder pain, 29% had back pain, and 10% had lower extremity pain (eg, hip, thigh, lower leg, knee, ankle, and foot pain). Tramadol was the most commonly prescribed opioid analgesic (82%), followed by codeine (13%). Ninety-seven percent of patients who were prescribed non-opioid analgesics had shoulder pain. Patients with shoulder pain had lower odds of receiving opioid analgesics (OR=0.019, P<0.0001, 95% CI=0.004–0.081) in comparison to their counterparts who had lower extremity or back pains. Moreover, the higher the pain score on activity was, the higher odds of receiving opioid analgesics (OR=1.317, P<0.0001, 95% CI=1.029–1.685). Conclusion Future studies should explore the impact of different opioid prescribing policies to improve the quality of patient care and reduce the unnecessary prescribing of opioids for patients with non-cancer musculoskeletal pain.
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Affiliation(s)
- Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.,Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hawazin Alhazzani
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ghaida Alhindi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Maryam Alarfaj
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Lama Almutairi
- Department of Pharmacy, King Abdulaziz University Hospital, Riyadh, Saudi Arabia
| | - Miteb Alanazi
- Department of Pharmacy, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Khaulah Alokili
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nouf Alanazi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Faris Alodaibi
- Department of Rehabilitation Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - Monira Alwhaibi
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Adel S Bashatah
- Department of Nursing Education and Administration, College of Nursing, King Saud University, Riyadh, Saudi Arabia
| | - Yousif Asiri
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Hisham Alsanawi
- Department of Orthopedic Surgery, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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De Sola H, Dueñas M, Salazar A, Ortega-Jiménez P, Failde I. Prevalence of Therapeutic use of Opioids in Chronic non-Cancer Pain Patients and Associated Factors: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:564412. [PMID: 33364942 PMCID: PMC7750787 DOI: 10.3389/fphar.2020.564412] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/16/2020] [Indexed: 02/01/2023] Open
Abstract
Objectives: To determine the prevalence and factors associated with the use of opioids among patients with chronic non-cancer pain (CNCP). Methods: A systematic review and meta-analysis. Comprehensive literature searches in Medline-PubMed, Embase and SCOPUS databases. Original studies published between 2009 and 2019 with a cross-sectional design were included. The quality of the studies was assessed with Critical Appraisal Checklist for Studies Reporting Prevalence Data from the Joanna Briggs Institute. Protocol registered in the International Prospective Register of Systematic Reviews with reference number: CRD42019137990. Results: Out of the 1,310 potential studies found, 25 studies fulfilled the inclusion criteria. Most of the studies were of high quality. High levels of heterogeneity were found in the studies included. In the general population, the prevalence of long-term opioid use was 2.3% (95% CI: 1.5–3.6%), the prevalence of short-term opioid use was 8.1% (95% CI: 5.6–11.6%), and among people with chronic low back pain it was 5.8% (95% CI: 0.5–45.5%). The prevalence of opioid use among patients from the health records or medical surveys was 41% (95% CI: 23.3–61.3%). Finally, in patients with musculoskeletal pain, the prevalence was 20.5% (95% CI: 12.9–30.9%) and in patients with fibromyalgia, 24.5% (95% CI: 22.9–26.2%). A higher prevalence of opioid use was observed among men, younger people, patients receiving prescriptions of different types of drugs, smokers and patients without insurance or with noncommercial insurance. In addition, non-white and Asian patients were less likely to receive opioids than non-Hispanic white patients. Conclusions: The prevalence of opioid use among patients with CNCP was higher in subjects with short or occasional use compared to those with long-term use. Men, younger people, more chronic pain conditions, and patients without insurance or with noncommercial insurance were most related to opioid use. However, non-white and Asian patients, and those treated by a physician trained in complementary medicine were less likely to use opioids.
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Affiliation(s)
- Helena De Sola
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Preventive Medicine and Public Health Area, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain
| | - María Dueñas
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain.,Department of Statistics and Operational Research, University of Cádiz, Cádiz, Spain
| | - Alejandro Salazar
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain.,Department of Statistics and Operational Research, University of Cádiz, Cádiz, Spain
| | - Patricia Ortega-Jiménez
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Department of Statistics and Operational Research, University of Cádiz, Cádiz, Spain
| | - Inmaculada Failde
- The Observatory of Pain, University of Cádiz, Cádiz, Spain.,Preventive Medicine and Public Health Area, University of Cádiz, Cádiz, Spain.,Biomedical Research and Innovation Institute of Cádiz (INiBICA), Research Unit, Puerta del Mar University Hospital, University of Cádiz, Cádiz, Spain
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Integrated Physical Medicine at Employer-Sponsored Health Clinics Improves Quality of Care at Reduced Cost. J Occup Environ Med 2020; 61:382-390. [PMID: 30640844 DOI: 10.1097/jom.0000000000001536] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate clinical and economic outcomes associated with integrating physical medicine in employer-sponsored clinics. METHODS Retrospective cohort analysis comparing clinical and economic outcomes of physical medicine services delivered in employer-sponsored clinics with the community. RESULTS Integrating physical medicine in employer-sponsored clinics decreased wait times to access these services to 7 days (2 to 4× faster than in the community). Patients receiving care in employer-sponsored clinics experienced marked improvements in fear of pain avoidance behaviors (P < 0.00001) and functional status (P < 0.01) in eight fewer visits than in the community (P < 0.0001), resulting in $472 to $630 savings/patient episode. Noncancer patients received 1/10th the opioid prescriptions in employer-sponsored clinics compared with the community (2.8% vs 20%). Patients were highly likely to recommend integrated employer-sponsored care (Net Promoter Score = 84.7). CONCLUSIONS Findings suggest robust clinical and economic benefits of integrating physical medicine services into employer-sponsored clinics.
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Busse JW, Sadeghirad B, Oparin Y, Chen E, Goshua A, May C, Hong PJ, Agarwal A, Chang Y, Ross SA, Emary P, Florez ID, Noor ST, Yao W, Lok A, Ali SH, Craigie S, Couban R, Morgan RL, Culig K, Brar S, Akbari-Kelachayeh K, Pozdnyakov A, Shergill Y, Sivananthan L, Zihayat B, Das A, Guyatt GH. Management of Acute Pain From Non-Low Back, Musculoskeletal Injuries : A Systematic Review and Network Meta-analysis of Randomized Trials. Ann Intern Med 2020; 173:730-738. [PMID: 32805127 DOI: 10.7326/m19-3601] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients and clinicians can choose from several treatment options to address acute pain from non-low back, musculoskeletal injuries. PURPOSE To assess the comparative effectiveness of outpatient treatments for acute pain from non-low back, musculoskeletal injuries by performing a network meta-analysis of randomized clinical trials (RCTs). DATA SOURCES MEDLINE, EMBASE, CINAHL, PEDro (Physiotherapy Evidence Database), and Cochrane Central Register of Controlled Trials to 2 January 2020. STUDY SELECTION Pairs of reviewers independently identified interventional RCTs that enrolled patients presenting with pain of up to 4 weeks' duration from non-low back, musculoskeletal injuries. DATA EXTRACTION Pairs of reviewers independently extracted data. Certainty of evidence was evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. DATA SYNTHESIS The 207 eligible studies included 32 959 participants and evaluated 45 therapies. Ninety-nine trials (48%) enrolled populations with diverse musculoskeletal injuries, 59 (29%) included patients with sprains, 13 (6%) with whiplash, and 11 (5%) with muscle strains; the remaining trials included various injuries ranging from nonsurgical fractures to contusions. Topical nonsteroidal anti-inflammatory agents (NSAIDs) proved to have the greatest net benefit, followed by oral NSAIDs and acetaminophen with or without diclofenac. Effects of these agents on pain were modest (around 1 cm on a 10-cm visual analogue scale, approximating the minimal important difference). Regarding opioids, compared with placebo, acetaminophen plus an opioid improved intermediate pain (1 to 7 days) but not immediate pain (≤2 hours), tramadol was ineffective, and opioids increased the risk for gastrointestinal and neurologic harms (all moderate-certainty evidence). LIMITATIONS Only English-language studies were included. The number of head-to-head comparisons was limited. CONCLUSION Topical NSAIDs, followed by oral NSAIDs and acetaminophen with or without diclofenac, showed the most convincing and attractive benefit-harm ratio for patients with acute pain from non-low back, musculoskeletal injuries. No opioid achieved benefit greater than that of NSAIDs, and opioids caused the most harms. PRIMARY FUNDING SOURCE National Safety Council. (PROSPERO: CRD42018094412).
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Affiliation(s)
- Jason W Busse
- McMaster University and Chronic Pain Centre of Excellence for Canadian Veterans, Hamilton, Ontario, Canada (J.W.B.)
| | - Behnam Sadeghirad
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Yvgeniy Oparin
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Eric Chen
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Anna Goshua
- Stanford University, Stanford, California (A.G.)
| | - Curtis May
- University of British Columbia, Vancouver, British Columbia, Canada (C.M.)
| | - Patrick J Hong
- University of Toronto, Toronto, Ontario, Canada (P.J.H., A.A., K.C.)
| | - Arnav Agarwal
- University of Toronto, Toronto, Ontario, Canada (P.J.H., A.A., K.C.)
| | - Yaping Chang
- McMaster University, Hamilton, and OrthoEvidence, Burlington, Ontario, Canada (Y.C.)
| | - Stephanie A Ross
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Peter Emary
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Ivan D Florez
- McMaster University, Hamilton, Ontario, Canada, and University of Antioquia, Medellin, Colombia (I.D.F.)
| | - Salmi T Noor
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - William Yao
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Annie Lok
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Syed Hussain Ali
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Samantha Craigie
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Rachel Couban
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Rebecca L Morgan
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Kayli Culig
- University of Toronto, Toronto, Ontario, Canada (P.J.H., A.A., K.C.)
| | - Sonia Brar
- University at Buffalo, Buffalo, New York (S.B.)
| | - Khashayar Akbari-Kelachayeh
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Alex Pozdnyakov
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Yaad Shergill
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | | | | | - Aninditee Das
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
| | - Gordon H Guyatt
- McMaster University, Hamilton, Ontario, Canada (B.S., Y.O., E.C., S.A.R., P.E., S.T.N., W.Y., A.L., S.H.A., S.C., R.C., R.L.M., K.A., A.P., Y.S., A.D., G.H.G.)
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Watanabe JH, Yang J. Hospitalization and Combined Use of Opioids, Benzodiazepines, and Muscle Relaxants in the United States. Hosp Pharm 2020; 55:286-291. [PMID: 32999498 PMCID: PMC7502868 DOI: 10.1177/0018578719894702] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Introduction: Concurrent opioid and benzodiazepine use ("double-threat") and double-threat and muscle relaxant use ("triple-threat") are postulated to increase morbidity versus opioids alone. Study objectives were to measure association between double- and triple-threat exposure and hospitalizations in a validated, nationally representative database of the United States. Methods: A retrospective cohort study was conducted using the 2013 and 2014 Medical Expenditure Panel Survey (MEPS) longitudinal dataset and affiliated Prescribed Medicines Files. Association between 2013 and 2014 double- and triple-threat exposures and outcome of hospitalizations compared to nonusers, opioid users, and all combinations were assessed via logistic regression. The cohort surveyed in MEPS has been weighted to be reflective of the actual US population in the years 2013 and 2014. Logistic regression applying the subject-level MEPS survey weights was performed to measure association via odds ratios (ORs) of medication exposures with the outcome of all-cause hospitalization. Study subjects were categorized into exposure groups as nonusers (nonuse of opioids, benzodiazepines, or muscle relaxants), opioid users, benzodiazepine users, muscle relaxant users, "double-threat" users, and "triple-threat" users. Analyses were conducted using RStudio® 1.1.5 (Boston, MA) with α level = 0.05 for all comparisons. Results: Opioids, benzodiazepines, and muscle relaxants were used in 11.9% (38.4 million), 4.2% (13.5 million), and 3.4% (10.9 million) lives of the United States in 2013, respectively. Double-threat prevalence rose from 1.6% to 1.9% from 2013 to 2014. Triple-threat prevalence remained unchanged at 0.53%. Compared to nonusers, triple-threat patients increased hospitalization probability with ORs of 8.52 (95% confidence interval [CI]: 8.50-8.55) in 2013, 5.06 (95% CI: 5.04-5.08) in 2014, and 4.61 (95% CI: 4.59-4.63) in the 2013-2014 longitudinal analysis. Compared to nonusers, double-threat patients increased hospitalization probability with ORs of 5.71 (95% CI: 5.69-5.72) in 2013, 11.47 (95% CI: 11.44-11.49) in 2014, and 5.59 (95% CI: 5.57-5.60) in the longitudinal analysis. Conclusion: Concurrent opioid and benzodiazepine use and opioid, benzodiazepine, and muscle relaxant use were associated with increased hospitalization likelihood. Amplified efforts in surveillance, prescribing, monitoring, and deprescribing for concurrent opioid, benzodiazepine, and muscle relaxant use are needed to reduce this public health concern.
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Koffel E, DeRonne B, Hawkins EJ. Co-prescribing of Opioids with Benzodiazepines and Other Hypnotics for Chronic Pain and Insomnia: Trends and Health Outcomes. PAIN MEDICINE 2020; 21:2055-2059. [PMID: 32186734 DOI: 10.1093/pm/pnaa054] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- University of Minnesota Medical School, Minneapolis, Minnesota
| | - Beth DeRonne
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington, USA
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Thorlund JB, Roos EM, Goro P, Ljungcrantz EG, Grønne DT, Skou ST. Patients use fewer analgesics following supervised exercise therapy and patient education: an observational study of 16 499 patients with knee or hip osteoarthritis. Br J Sports Med 2020; 55:670-675. [PMID: 32958468 DOI: 10.1136/bjsports-2019-101265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate changes in analgesic use before and after supervised exercise therapy and patient education in patients with knee or hip osteoarthritis (OA). METHODS We recruited 16 499 of 25 933 eligible patients (64%; mean age 64.9; SD 9.6; 73% women) from the Good Life with osteoArthritis in Denmark (GLA:D) registry. Change in proportions of analgesic users (categorised according to analgesic risk profile; opioids > non-steroidal anti-inflammatory drugs > paracetamol) was assessed from before to after an 8-week supervised exercise therapy and patient education programme targeting knee or hip OA pain and functional limitations. RESULTS Patients reported 13.2 mm (95% CI 12.8 to 13.6) less pain (visual analogue scale 0-100 mm) at follow-up compared with baseline. The proportion of analgesic users reduced from 62.2% (95% CI 61.5 to 63.0) at baseline to 44.1% (95% CI 43.3 to 44.9) at follow-up (absolute change: 18.1% (95% CI 17.3 to 19.0)). Among patients using analgesics at baseline, 52% changed to a lower risk analgesic or discontinued analgesic use. The proportion of opioid users after the exercise therapy was 2.5% (95% CI 2.1 to 2.9) lower than baseline; this represents a relative reduction of 36%. CONCLUSION Among patients with knee or hip OA using analgesics, more than half either discontinued analgesic use or shifted to lower risk analgesics following an 8-week structured exercise therapy and patient education programme (GLA:D). These data encourage randomised controlled trial evaluation of whether supervised exercise therapy, combined with patient education, can reduce analgesic use, including opioids, among patients with knee and hip OA pain.
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Affiliation(s)
- Jonas Bloch Thorlund
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark .,Research Unit for General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ewa M Roos
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Patricia Goro
- School of Medicine, Örebro University, Örebro, Sweden
| | | | - Dorte Thalund Grønne
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark
| | - Søren T Skou
- Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense M, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
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Petzke F, Bock F, Hüppe M, Nothacker M, Norda H, Radbruch L, Schiltenwolf M, Schuler M, Tölle T, Viniol A, Häuser W. Long-term opioid therapy for chronic noncancer pain: second update of the German guidelines. Pain Rep 2020; 5:e840. [PMID: 32904018 PMCID: PMC7447355 DOI: 10.1097/pr9.0000000000000840] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/21/2020] [Accepted: 06/29/2020] [Indexed: 11/26/2022] Open
Abstract
The opioid epidemic in North America challenges national guidelines worldwide to define the importance of opioids for the management of chronic noncancer pain (CNCP). METHODS The second update of the German guidelines on long-term opioid therapy for CNCP was developed by 26 scientific associations and 2 patient self-help organizations. A systematic literature search in CENTRAL, Medline, and Scopus (to May 2019) was performed. Meta-analyses of randomized controlled trials and open-label extension studies with opioids for CNCP were conducted. Levels of evidence were assigned according to the Oxford Centre for Evidence-Based Medicine classification system. The formulation and strength of recommendations were established by multistep formalized procedures to reach a consensus according to German Association of the Medical Scientific Societies regulations. The guidelines underwent external review by 4 experts and public commentary. RESULTS Opioids are one drug-based treatment option for short- (4-12 weeks), intermediate- (13-26 weeks), and long-term (>26 weeks) therapy of chronic pain in osteoarthritis, diabetic polyneuropathy, postherpetic neuralgia, and low back pain. Contraindications are primary headaches, functional somatic syndromes, and mental disorders with the (cardinal) symptom of pain. For specified other clinical pain conditions, short- and long-term therapy with opioids should be evaluated on an individual basis. Long-term therapy with opioids is associated with relevant risks. CONCLUSION Responsible application of opioids requires consideration of possible indications and contraindications, as well as regular assessment of clinical response and adverse effects. Neither uncritical opioid prescription nor general rejection of opioids is justified in patients with CNCP.
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Affiliation(s)
- Frank Petzke
- Pain Medicine, Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Frietjof Bock
- Orthopaedics at the Green Tower, Ravensburg, Germany
| | - Michael Hüppe
- Department Anesthesiology and Intensive Care Medicine, Universität zu Lübeck, Lübeck, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management (AWMF-IMWi), Berlin, Germany
| | | | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Marcus Schiltenwolf
- Department of Orthopedics and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias Schuler
- Clinic for Geriatric Medicine, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Thomas Tölle
- Department of Neurology, Technische Universität München, München, Germany
| | - Anika Viniol
- Department of General Medicine, Preventive and Rehabilitation Medicine, University of Marburg, Marburg, Germany
| | - Winfried Häuser
- Department Internal Medicine I, Klinikum Saarbrücken, Saarbrücken, Germany
- Department Psychosomatic Medicine and Psychotherapy, Technische Universität München, München, Germany
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43
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Staffa JA. Keeping the Pharmacology in Pharmacoepidemiology. Clin Pharmacol Ther 2020; 109:1393-1394. [PMID: 32827442 DOI: 10.1002/cpt.2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/26/2020] [Indexed: 11/11/2022]
Abstract
The treatment of many medical conditions requires the use of multiple drugs. A study published recently in this journal nicely illustrates the need to consider the pharmacology of potentially interacting drugs when conducting pharmacoepidemiologic studies of patient safety outcomes associated with such interactions. By examining multiple streams of data, we can piece together the risks and the mechanisms of action underlying those risks, and provide useful information for clinicians and patients to use multiple pharmacotherapies safely.
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Affiliation(s)
- Judy A Staffa
- Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Fulton-Kehoe D, Lofy KH, Le V, Sterling R, Sears JM, Franklin G. Opioid-Prescribing Metrics in Washington State: Trends and Challenges. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2020; 26:214-221. [DOI: 10.1097/phh.0000000000001149] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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Li Y, Delcher C, Wei YJJ, Reisfield GM, Brown JD, Tighe P, Winterstein AG. Risk of Opioid Overdose Associated With Concomitant Use of Opioids and Skeletal Muscle Relaxants: A Population-Based Cohort Study. Clin Pharmacol Ther 2020; 108:81-89. [PMID: 32022906 DOI: 10.1002/cpt.1807] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/28/2020] [Indexed: 12/20/2022]
Abstract
The recent opioid prescribing guideline cautions about the concomitant prescribing of opioids and skeletal muscle relaxants (SMRs) given the additive central nervous system depressant effect. However, the clinical relevance remains unclear. In this retrospective cohort study, we compared the risk of opioid overdose associated with concomitant use of opioids and SMRs vs. opioid use alone. Adjusted hazard ratios were 1.09 (95% confidence interval (CI), 0.74-1.62) and 1.26 (95% CI, 1.00-1.58) in the incident and prevalent opioid user cohorts, respectively, generating a combined estimate of 1.21 (95% CI, 1.00-1.48). This risk seemed to increase with treatment duration (≤ 14 days: 0.91 and 95% CI, 0.67-1.22; 15-60 days: 1.37 and 95% CI, 0.81-2.37; >60 days: 1.80 and 95% CI, 1.30-2.48) and for baclofen (1.83 and 95% CI, 1.11-3.04) and carisoprodol (1.84 and 95% CI, 1.34-2.54). Concomitant users with daily opioid dose ≥50 mg (1.50 and 95% CI, 1.18-1.92) and benzodiazepine use (1.39 and 95% CI, 1.08-1.79) also had elevated risk. Clinicians should be cautious about these potentially unsafe practices to optimize pain care and improve patient safety.
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Affiliation(s)
- Yan Li
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Chris Delcher
- Institute for Pharmaceutical Outcomes & Policy, Department of Pharmacy Practice & Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky, USA
| | - Yu-Jung Jenny Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Gary M Reisfield
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
| | - Patrick Tighe
- Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, Florida, USA
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Young SD, Lee SJ, Perez H, Gill N, Gelberg L, Heinzerling K. Social media as an emerging tool for reducing prescription opioid misuse risk factors. Heliyon 2020; 6:e03471. [PMID: 32181385 PMCID: PMC7062763 DOI: 10.1016/j.heliyon.2020.e03471] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 12/10/2019] [Accepted: 02/10/2020] [Indexed: 12/23/2022] Open
Abstract
Interventions are urgently needed to reduce prescription opioid misuse risk factors, including anxiety and concomitant use of sedatives. However, only a limited number of randomized controlled opioid intervention trials have been conducted. We sought to determine whether an online behavior change/support community, compared to a control Facebook group, could reduce anxiety and opioid misuse among chronic pain patients. 51 high-risk non-cancer chronic pain patients were randomly assigned to either a Harnessing Online Peer Education (HOPE) peer-led online behavior change intervention or a control group (no peer leaders) on Facebook for 12 weeks. Inclusion criteria were: 18 years or older, a UCLA Health System patient, prescribed an opioid for non-cancer chronic pain between 3 and 12 months ago, and a score of ≥9 on the Current Opioid Misuse Measure (COMM) and/or concomitant use of benzodiazepines. Participation in the online community was voluntary. Patients completed baseline and follow-up assessments on Generalized Anxiety Disorder screener (GAD-7), COMM, and frequency of social media discussions about pain and opioid use. Compared to control group participants, intervention participants showed a baseline-to-follow-up decrease in anxiety, and more frequently used social media to discuss pain, prescription opioid use, coping strategies, places to seek help, and alternative therapies for pain. Both groups showed a baseline to follow-up decrease in COMM score. Preliminary results support the use an online community interventions as a low-cost tool to decrease risk for prescription opioid misuse and its complications.
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Affiliation(s)
- Sean D. Young
- Department of Informatics, School of Information and Computer Sciences, University of California, Irvine, CA, USA
- Department of Emergency Medicine, School of Medicine, University of California, Irvine, CA, USA
- Corresponding author.
| | - Sung-Jae Lee
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Hendry Perez
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Navkiran Gill
- University of California Institute for Prediction Technology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Keith Heinzerling
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Gause TM, Nunnery JJ, Chhabra AB, Werner BC. Perioperative Narcotic Use and Carpal Tunnel Release: Trends, Risk Factors, and Complications. Hand (N Y) 2020; 15:234-242. [PMID: 30067126 PMCID: PMC7076616 DOI: 10.1177/1558944718792276] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background: The goals of the study were to: (1) evaluate trends in preoperative and prolonged postoperative narcotic use in carpal tunnel release (CTR); (2) characterize risks for prolonged narcotic use; and (3) evaluate narcotic use as an independent risk factor for complications following CTR. Methods: A query of a large insurance database from 2007-2016 was conducted. Patients undergoing open or endoscopic CTR were included. Revision surgeries or patients undergoing median nerve repair at the forearm, upper extremity fasciotomies, or with distal radius fractures were excluded. Preoperative use was defined as narcotic use between 1 to 4 months prior to CTR. A narcotic prescription between 1 and 4 months after surgery was considered prolonged postoperative use. Demographics, comorbidities, and other risk factors for prolonged postoperative use were assessed using a regression analysis. Subgroup analysis was performed according to the number of preoperative narcotic prescriptions. Narcotic use as a risk factor for complications, including chronic regional pain syndrome (CRPS) and revision CTR, was assessed. Results: In total, 66 077 patients were included. A decrease in prescribing of perioperative narcotics was noted. Risk factors for prolonged narcotic use included preoperative narcotic use, drug and substance use, lumbago, and depression. Preoperative narcotics were associated with increased emergency room visits, readmissions, CRPS, and infection. Prolonged postoperative narcotic use was linked to CRPS and revision surgery. Conclusions: Preoperative narcotic use is strongly associated with prolonged postoperative use. Both preoperative and prolonged postoperative prescriptions narcotic use correlated with increased risk of complications. Preoperative narcotic use is associated with a higher risk of postoperative CRPS.
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Thorlund JB, Turkiewicz A, Prieto-Alhambra D, Englund M. Inappropriate opioid dispensing in patients with knee and hip osteoarthritis: a population-based cohort study. Osteoarthritis Cartilage 2020; 28:146-153. [PMID: 31669311 DOI: 10.1016/j.joca.2019.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/16/2019] [Accepted: 10/01/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To estimate inappropriate opioid dispensing in patients with knee or hip osteoarthritis (OA) defined as (1) dispensing of opioids within the first year of diagnosis or (2) long-term opioid use. DESIGN Data from Skåne Healthcare Register was linked with the Swedish Prescribed Drug Register. Incidence proportion of dispensed opioids within first year of incident knee or hip OA diagnosis was determined in knee (n = 399,670) and hip (413,216) OA cohorts without a history of OA. The 1-year period prevalence of long-term opioid dispensing was determined in a prevalence cohort (n = 48,574 with knee and/or hip OA and n = 457,587 without OA). The proportion of OA patients with excess opioid dispensing attributable to OA was estimated using inverse probability weighted regression adjustment. RESULTS In the incident cohorts, 5866 and 2359 developed knee and hip OA, respectively. Within the first year after OA diagnosis 14.7% patients with knee OA and 20.7% with hip OA had an opioid dispensed. The estimated inappropriate dispensing attributable to OA was 7.4% (95% CI 6.5-8.4) for knee OA and 12.8% (95% CI 11.1-14.4) for hip OA. Among persons with prevalent knee, hip or knee and hip OA inappropriate, long-term opioid use attributable to OA was 1.3%, 2.0% and 2.4% of, respectively. CONCLUSIONS More than half the incident opioid dispensations to patients within their first year after knee or hip OA diagnosis are inappropriate according to current treatment guidelines. Furthermore, 2% of patients with prevalent knee or hip OA have inappropriate long-term dispensing of opioids.
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Affiliation(s)
- J B Thorlund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden; Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark.
| | - A Turkiewicz
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden
| | - D Prieto-Alhambra
- GREMPAL (Grup de Recerca en Epidemiologia de les Malalties Prevalents de l'Aparell Locomotor), Idiap Jordi Gol Primary Care Research Institute and CIBERFes, Universitat Autònoma de Barcelona and Instituto de Salud Carlos III, Barcelona, Spain; Pharmaco- and Device Epidemiology, Centre for Statistics in Medicine - Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, UK
| | - M Englund
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund, Sweden; Clinical Epidemiology Research and Training Unit, Boston University School of Medicine, Boston, MA, USA
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Abstract
Developing effective analgesics with fewer unwanted side effects is a pressing concern. Due to a lack of effective nonopioid options currently available, an alternative approach termed opioid-sparing evaluates the ability of a coadministered drug to reduce the amount of opioid needed to produce an antinociceptive effect. Opioids and benzodiazepines are often coprescribed. Although this approach is theoretically rational given the prevalent comorbidity of chronic pain and anxiety, it also has inherent risks of respiratory depression, which is likely responsible for the substantial percentage of fatal opioid overdoses that have involved benzodiazepines. Moreover, there have been no clinical trials to support the effectiveness of this drug combination nor has there been corroborative preclinical evidence using traditional animal models of nociception. The present studies examined the prescription µ-opioid analgesic oxycodone (0.003-0.1 mg/kg) and the prototypical benzodiazepine anxiolytic diazepam (0.03-1.0 mg/kg), alone and in combination, using an animal model of pain that examines the restoration of conflict-related operant behavior as evidence of analgesia. Results documented significant dose-related increases in thermal threshold following oxycodone treatment. Diazepam treatment alone did not produce significant antinociception. In combination, diazepam pretreatment shifted oxycodone functions upward in a dose-dependent manner, but the additive effects were limited to a narrow dose range. In addition, combinations of diazepam and oxycodone at higher doses abolished responding. Taken together, though intriguing, these findings do not provide sufficient evidence that coadministration of an anxiolytic will result in clinically relevant opioid-sparing for pain management, especially when considering the inherent risks of this drug class combination.
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50
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Koffel E, Amundson E, Wisdom JP. Exploring the Meaning of Cognitive Behavioral Therapy for Insomnia for Patients with Chronic Pain. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:67-75. [PMID: 31271434 PMCID: PMC6942230 DOI: 10.1093/pm/pnz144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Insomnia is one of the most common, persistent, and distressing symptoms associated with chronic pain. Cognitive behavioral therapy for insomnia (CBT-I) is the firstline treatment for insomnia, but patient preferences and perspectives about CBT-I within the context of chronic pain are unknown. The current qualitative study sought to understand the experience of CBT-I among patients with chronic pain, including aspects of CBT-I that were found to be difficult (e.g., pain as a specific barrier to adherence/dropout), changes in sleep and pain functioning after CBT-I, and aspects of CBT-I that were appreciated. DESIGN Qualitative semistructured interviews. METHODS We conducted individual semistructured interviews with 17 veterans with chronic pain and insomnia who had recently participated in CBT-I, as well as their CBT-I therapists, and used thematic analysis to identify conceptual themes. RESULTS Results revealed that patients and CBT-I therapists found changing sleep habits during CBT-I challenging due to anxiety and temporary increases in fatigue, but did not identify major pain-related barriers to adhering to CBT-I recommendations; patients experienced better sleep, mood, energy, and socialization after CBT-I despite minimal changes in pain intensity; and patients highly valued CBT-I as a personalized treatment for sleep and strongly recommended it for other patients with chronic pain. CONCLUSIONS Findings of improved sleep and functional outcomes support efforts to incorporate CBT-I into chronic pain treatment, including educating patients and providers about the strong feasibility of improving sleep and quality of life despite ongoing pain.
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Affiliation(s)
- Erin Koffel
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
- Department of Psychiatry, University of Minnesota Medical School, Minneapolis, MN
| | - Erin Amundson
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN
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